State of Illinois
90th General Assembly

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      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  Public  Health.  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 Public Health shall issue an annual report on
      the performance of managed care entities.
 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 Public
13    Health.
14        "Director" means the Director of Public Health.
15        "Emergency care services" means dental services  provided
16    for an emergency dental condition.
17        "Emergency  dental  condition"  means  a dental condition
18    manifesting itself by acute symptoms of sufficient  severity,
19    including  severe  pain,  so  that  the  absence of immediate
20    dental attention could reasonably be expected to result in:
21             (1) placing the health of the individual in  serious
22        jeopardy;
23             (2) serious impairment to a bodily function; or
24             (3)  serious  dysfunction of an organ or part of the
25        body.
26        "Managed  care  dental  plan"  or  "plan"  means  a  plan
27    operated by a managed  care  entity  that  provides  for  the
28    financing  and  delivery of dental care or dental services to
29    persons enrolled in the plan through:
30             (1)  arrangements with selected providers to furnish
31        dental services;
                            -2-               LRB9000645JSmgB
 1             (2)  explicit  standards  for   the   selection   of
 2        participating providers;
 3             (3)  organizational arrangements for ongoing quality
 4        assurance, utilization  review, and  dispute  resolution;
 5        or
 6             (4)  differential coverages or payments or financial
 7        incentives for a person enrolled in the plan to  use  the
 8        participating  providers  and  procedures provided by the
 9        plan.
10        "Point-of-service plan" means a plan provided  through  a
11    contractual  arrangement  under  which indemnity benefits for
12    the cost of dental care services, other than  emergency  care
13    services,  are provided by an insurer or other corporation in
14    conjunction with corresponding benefits  arranged or provided
15    by a health  maintenance  organization,  including  a  single
16    service  health  maintenance organization.  An individual may
17    choose to  obtain  benefits  or  services  under  either  the
18    indemnity plan or the health maintenance organization plan in
19    accordance  with  specific  provisions  of a point-of-service
20    contract.
21        "Prospective enrollee" means an individual  eligible  for
22    enrollment   in   a   managed   care  plan  offered  by  that
23    individual's employer.
24        "Provider" means either a general dentist  or  a  dentist
25    who is a licensed specialist.
26        Section  15. Rules; advisory committee.  The Director may
27    adopt rules regarding standards ensuring compliance with this
28    Act by managed care entities that conduct  business  in  this
29    State.   The  Director  may  appoint an advisory committee to
30    assist in the implementation of this Act.
31        Section 20.  Disclosure.
32        (a)  A managed care entity shall  provide  a  prospective
                            -3-               LRB9000645JSmgB
 1    enrollee  a  written  plan  description  of   the  terms  and
 2    conditions  of  the  dental  plan.   The  written dental plan
 3    description must be in a readable and  understandable  format
 4    and must include:
 5             (1)  coverage provisions;
 6             (2)   any  prior authorization, including procedures
 7        for and  limitations  or  restrictions  on  referrals  to
 8        providers  other  than  general dentists, or other review
 9        requirements,    including    preauthorization    review,
10        concurrent review, postservice  review,  and  postpayment
11        review;
12             (3)     an   explanation   of   enrollee   financial
13        responsibility  for  payment  for  coinsurance  or  other
14        noncovered or out-of-plan services; and
15             (4)  a  disclosure  to  prospective  enrollees  that
16        includes the following language:
17                   "YOUR RIGHTS UNDER ILLINOIS LAW
18             You  have  the right to information about the dental
19        plan, including how the plan operates, what general types
20        of financial arrangements exist between providers and the
21        plan, names and locations of  providers,  the  number  of
22        enrollees  and  providers  in the plan, the percentage of
23        premiums allocated for dental care, administrative costs,
24        and profit, and an explanation of the benefits  to  which
25        participants  are entitled under the terms of the plan.";
26        and
27             (5)  a phone number and address for the  prospective
28        enrollee  to obtain additional information concerning the
29        items described by paragraph (4) of this subsection.
30        (b)  The managed care entity may provide the  information
31    under  paragraph  (4)  of  subsection  (a)  of  this  Section
32    regarding  the  percentage  of  premiums allocated for dental
33    care, administrative  costs,  and  profit  by  providing  the
34    information  in  the entity's annual financial statement most
                            -4-               LRB9000645JSmgB
 1    recently submitted to the Department.
 2        (c)  The managed care entity shall demonstrate that  each
 3    covered  enrollee  has  adequate  access through the entity's
 4    provider network to all items and dental  services  contained
 5    in  the  package  of benefits for which coverage is provided.
 6    The access must be adequate considering the diverse needs  of
 7    enrollees.
 8        (d)   Nothing  in  subsection  (c) of this Section may be
 9    interpreted to circumvent  the  managed  care  plan's  normal
10    referral and authorization processes.
11        (e)  If the managed care plan uses a capitation method of
12    compensation,  the  plan must establish and follow procedures
13    that ensure that:
14             (1)  the plan application form includes a  space  in
15        which each enrollee selects a dentist;
16             (2)   an  enrollee who fails to select a dentist and
17        is assigned  a  dentist  is  notified  of  the  name  and
18        location of that dentist; and
19             (3)   a  dentist  to whom an enrollee is assigned is
20        physically located within a reasonable  travel  distance,
21        as  established by rule adopted by the Director, from the
22        residence or place of employment of the enrollee.
23        Section 25.  Explanation of network  configuration.   The
24    managed  care  entity  shall  provide  to  the  Director, for
25    information, an explanation of the targeted dentist, and,  as
26    appropriate,  other provider network configuration, including
27    geographic  distribution  of  dentists  by  specialty.    The
28    information  required  by  this  Section  shall be updated at
29    least:
30             (1)  on establishment of a new managed  care  dental
31        plan;
32             (2)  on expansion of a service area; or
33             (3)   when  the  network  configuration  targets are
                            -5-               LRB9000645JSmgB
 1        significantly modified.
 2        Nothing in this Section shall require a particular  ratio
 3    for  any  type  of  provider.   The information shall be made
 4    available to the public by the Department  on  request.   The
 5    Department  may  charge  a  reasonable  fee for providing the
 6    information.
 7        Section 30.  Financial  incentives  that  limit  services
 8    prohibited.   A  managed  care  dental  plan  may  not  use a
 9    financial incentive program that limits  medically  necessary
10    and appropriate services.
11        Section  35.  Credentialing; utilization review; provider
12    input.
13        (a)   A  managed  care  dental  plan  shall  establish  a
14    mechanism under which  dentists  participating  in  the  plan
15    provide  consultation and advice on the plan's dental policy,
16    including  coverage  of  a  new  technology  and  procedures,
17    utilization  review  criteria  and  procedures,  quality  and
18    credentialing criteria,  and  dental  management  procedures.
19    Other  participating  providers shall be given an opportunity
20    to comment on the plan's policies affecting  their  services.
21    A  managed  care  dental plan on request shall make available
22    and  disclose  to  providers  the  application  process   and
23    qualification  requirements  for  participation  in the plan.
24    The plan  must  give  a  provider  not  selected  on  initial
25    application a reason why the initial application was denied.
26        (b)   A  dentist  under  consideration for inclusion in a
27    managed care dental plan shall be reviewed by a credentialing
28    committee  composed  primarily   of   network   participating
29    dentists  selected by the dental director of the managed care
30    entity.  If there are no credentialed  dentists  in  a  newly
31    created  plan,  the  committee shall be primarily composed of
32    dentists practicing in the same or similar  settings.   Other
                            -6-               LRB9000645JSmgB
 1    providers  may  be credentialed if appropriate, as determined
 2    by the plan.  When a provider, other than a general  dentist,
 3    is  credentialed  by  the  plan,  the credentialing committee
 4    shall include providers with the same license.
 5        (c)   Credentialing  of  providers  shall  be  based   on
 6    identified   standards   developed  after  consultation  with
 7    providers  credentialed  in  the  plan.   If  there  are   no
 8    credentialed  providers  in  a  newly  created plan, the plan
 9    shall develop credentialing standards after  consulting  with
10    area  providers.  The managed care dental plan shall make the
11    credentialing standards available to applicants.
12        (d)  If economic considerations are part of the  decision
13    to select a provider or terminate a contract with a provider,
14    the  plan  shall  use  identified  criteria  which  shall  be
15    available  to applicants and participating providers.  If the
16    plan uses an economic profile of a provider,  the  plan  must
17    adjust  the  profile  to  recognize  the characteristics of a
18    provider's practice that  may  account  for  variations  from
19    expected costs.
20        (e)   A  managed  care  dental plan that conducts or uses
21    economic profiling of providers within the  plan  shall  make
22    the  profile available to the provider profiled on a periodic
23    basis.
24        (f)  A managed care  dental  plan  shall  have  a  dental
25    director  who  is  a  licensed  dentist.  The dental director
26    shall be responsible for the clinical decisions made  by  the
27    plan  and  provide  assurance  that  the dental decisions and
28    review policies that are used  by  the  plan  are  clinically
29    appropriate  and  based on the commonly accepted standards of
30    care.
31        Decisions made  by  the  plan  to  deny  coverage  for  a
32    procedure,  or  that  a  payment for an alternative procedure
33    should be considered, must be made by the dental director  or
34    a  licensed  dentist acting under the direct authority of the
                            -7-               LRB9000645JSmgB
 1    dental director. When claims are  denied  or  an  alternative
 2    procedure is offered by the plan, the decisions must indicate
 3    the  name  of  the  dentist  who made the determination and a
 4    telephone number and business hours where the dentist can  be
 5    contacted directly to discuss the clinical determination.
 6        Upon  request,  enrollees or the provider may request the
 7    credentials of the individual who has recommended a denial or
 8    has offered an alternative procedure for payment for specific
 9    claim. An enrollee or provider who has had a claim denied  or
10    was  offered  an  alternative benefit for payment by the plan
11    shall be provided the opportunity for a due process appeal to
12    a licensed dentist  who  was  not  involved  in  the  initial
13    decision.
14        (g)  Unless  specifically required by this Act, a managed
15    care dental plan is  not  required  to  disclose  proprietary
16    information regarding marketplace strategies.
17        (h)  A  managed  care  dental  plan  may  not  exclude  a
18    provider solely because of the anticipated characteristics of
19    the patients of that provider.
20        (i)  Before  terminating  a contract with a provider, the
21    managed care dental plan shall provide a written  explanation
22    of   the   reasons   for   termination,  an  opportunity  for
23    discussion, and an opportunity to enter into and  complete  a
24    corrective  action plan, if appropriate, as determined by the
25    plan.  Except in cases in which there  is  imminent  harm  to
26    patient health or an action by the Department of Professional
27    Regulation   or  other  government  agency  that  effectively
28    impairs the provider's ability to practice dentistry,  or  in
29    cases  of  fraud  or  malfeasance,  on request and before the
30    effective date of the termination, the provider  is  entitled
31    to  a review of the plan's proposed action by a plan advisory
32    panel.  For a  dentist,  the  plan  advisory  panel  must  be
33    primarily   composed  of the dentist's peers.  The review may
34    include a review of the appropriateness and requirements of a
                            -8-               LRB9000645JSmgB
 1    corrective action plan.  The decision of the  advisory  panel
 2    must be considered but is not binding on the plan.
 3        (j)   If  the  action that is under consideration is of a
 4    type that must be reported to the National Practitioner  Data
 5    Bank  or  the  Department  of  Professional Regulation  under
 6    federal or State law, the dentist's  procedural  rights  must
 7    meet  the  standards  set  forth  in  the federal Health Care
 8    Quality Improvement Act of 1986, 42 U.S.C. 11101 et seq.
 9        (k)  A  communication  relating  to  the  subject  matter
10    provided  for under subsection (a) or (i) of this Section may
11    not be the basis for a cause of action for libel  or  slander
12    except  for  disclosures or communications with parties other
13    than the plan or provider.
14        (l)   The  managed  care  dental  plan  shall   establish
15    reasonable  procedures for assuring a transition of enrollees
16    of the plan to new providers.
17        (m)  If a contract with a provider  is  terminated  by  a
18    managed  care  dental  plan,  the  plan  shall  reimburse the
19    provider the reasonable cost for copies of medical or  dental
20    records  that  are  furnished  to  another  provider  at  the
21    patient's  request.   If  a  provider terminates the contract
22    with the plan, the provider shall bear the reasonable cost of
23    providing copies of dental  records  that  are  furnished  to
24    another provider at the patient's request.
25        (n)   This  Act  does  not prohibit a managed care dental
26    plan from rejecting an application from a provider  based  on
27    the  determination  that  the  plan  has sufficient qualified
28    providers.
29        Section 40.  Coverage; prior  authorization.   A  managed
30    care dental plan shall:
31        (1)   cover  emergency  dental  care services provided to
32    covered individuals, without regard to whether  the  provider
33    furnishing   the   services   has   a  contractual  or  other
                            -9-               LRB9000645JSmgB
 1    arrangement with the entity to provide items or  services  to
 2    covered    individuals,    including    the   treatment   and
 3    stabilization of an emergency dental condition; and
 4        (2)  provide that the prior authorization requirement for
 5    medically necessary services provided  or  originating  in  a
 6    hospital   emergency   department   following   treatment  or
 7    stabilization of an emergency dental  condition  is  approved
 8    unless  denied  in  the time appropriate to the circumstances
 9    relating to the delivery of the services and the condition of
10    the patient, as  determined  by  the  treating  provider  and
11    communicated to the plan.
12        Section  45.  Prior authorization; consent forms.  A plan
13    for which prior authorization is a condition to coverage of a
14    service must ensure  that  enrollees  are  required  to  sign
15    dental information release consent forms on enrollment.
16        Section 50.  Point-of-service plans.
17        (a)   When  a  health  maintenance  organization offers a
18    managed care dental plan in its service area and is the  only
19    entity  providing  services  under  a dental benefit plan, it
20    must offer to  all  eligible  enrollees  the  opportunity  to
21    obtain  coverage  for  out-of-network  services  through  the
22    point-of-service  plan  as  defined by subsection (b) of this
23    Section at the time of enrollment and at least annually.
24        (b)  The premium for the point-of-service plan  shall  be
25    based on the actuarial value of that coverage.
26        (c)   Any additional  costs for the point-of-service plan
27    are the responsibility of the enrollee, and the employer  may
28    impose  a  reasonable  administrative  cost for providing the
29    point-of-service option.
30        (d)  When 5% or less of the  group's  eligible  employees
31    elect  to  purchase  the point-of-service option, the plan is
32    not required to  offer  the  point-of-service  option  during
                            -10-              LRB9000645JSmgB
 1    subsequent open enrollment periods.
 2        Section  55.  Private cause of action; existing remedies.
 3    This Act and rules adopted under this Act do not:
 4             (1)  provide a private cause of action  for  damages
 5        or  create  a  standard of care, obligation, or duty that
 6        provides a basis  for  a  private  cause  of  action  for
 7        damages; or
 8             (2)   abrogate  a  statutory  or common law cause of
 9        action,  administrative  remedy,  or  defense   otherwise
10        available  and existing before the effective date of this
11        Act.
12        Section 60.  Director's report.
13        (a)   The  Director  shall  issue  an  annual  report  to
14    consumers on the performance  of managed care entities.
15        (b)  The Director shall have access to:
16             (1)  information provided under Section 25  of  this
17        Act;
18             (2)  information contained in complaints relating to
19        managed  care  entities  made  to the Department provided
20        that the  Director shall  maintain  as  confidential  any
21        information in the complaint that relates to a patient or
22        that is made confidential by another law; and
23             (3)    any   statistical   information  relating  to
24        utilization, quality assurance,  and  complaints  that  a
25        health  maintenance  organization is required to maintain
26        under rules adopted by the Department.
27        (c)  The Director shall provide a copy of the report to a
28    person on request  on  payment  of  a  reasonable  fee.   The
29    Director  shall set the fee in the amount necessary to defray
30    the cost of producing the report.
31        Section 65.   Retaliation  prohibited.   A  managed  care
                            -11-              LRB9000645JSmgB
 1    dental  plan  may not take any retaliatory actions, including
 2    cancellation  or  refusal  to  renew  a  policy,  against  an
 3    employer or enrollee solely because the  enrollee  has  filed
 4    complaints with the plan or appealed a decision of the plan.
 5        Section 70.  Application of other law.
 6        (a)   All provisions of this Act and other applicable law
 7    which are not in  conflict  with  this  Act  shall  apply  to
 8    managed care entities and other persons subject to this Act.
 9        (b)   Solicitation  of enrollees by a managed care entity
10    granted a certificate of  authority  or  its  representatives
11    shall  not  be  construed  to  violate  any  provision of law
12    relating   to   solicitation   or   advertising   by   health
13    professionals.
14        Section 75.  Severability.  The provisions  of  this  Act
15    are severable under Section 1.31 of the Statute on Statutes.

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