PocketLaw | Illinois Compiled Statutes

Dental Care Patient Protection Act.

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(215 ILCS 109/1)

Sec. 1. Short title. This Act may be cited as the Dental Care Patient Protection Act.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/5)

Sec. 5. Purpose; dental care patient rights.

(a) The purpose of this Act is to provide fairness and choice to dental patients and dentists under managed care dental benefit plans.

(b) Dental care patients have the following rights:

(1) A patient has the right to care consistent with professional standards of practice to assure quality dental care, to choose the participating dentist responsible for providing his or her care, to receive information concerning his or her condition and proposed treatment, to refuse any treatment to the extent permitted by law, and to privacy and confidentiality of records except as otherwise provided by law.
(2) A patient has the right, regardless of source of payment, to examine and to receive a reasonable explanation of his or her total bill for services rendered by his or her dentist. A dentist shall be responsible only for a reasonable explanation of those specific dental care services provided by the dentist.
(3) A patient has the right to timely prior notice of the termination in the event a plan cancels or refuses to renew an enrollee's participation in the plan except when the termination is for non-payment of premium or termination of the plan by the group.
(4) A patient has the right to privacy and confidentiality. This right may be expressly waived in writing by the patient or the patient's guardian.
(5) A patient has the right to purchase any dental care services with that patient's own funds.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/10)

Sec. 10. Definitions. As used in this Act:

"Dental care services" means services permitted to be performed by a licensed dentist or any person working under the dentist's supervision as permitted by law.

"Dentist" means a person licensed to practice dentistry in any state.

"Department" means the Department of Insurance.

"Director" means the Director of Insurance.

"Emergency dental services" means the provision of dental care for a sudden, acute dental condition that would lead a prudent layperson, who possesses an average knowledge of dentistry, to reasonably expect the absence of immediate care to result in serious impairment to the dentition or would place the person's oral health in serious jeopardy.

"Enrollee" means an individual and his or her dependents who are enrolled in a managed care dental plan.

"Managed care dental plan" or "plan" means a plan that establishes, operates, or maintains a network of dentists that have entered into agreements with the plan to provide dental care services to enrollees to whom the plan has the obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution.

For the purpose of this Act, "managed care dental plans" do not include employee or employer self-insured dental benefit plans under the federal ERISA Act of 1974.

"Point-of-service plan" means a plan or plans that includes both in-plan covered services and out-of-plan covered services as well as managed dental care plan arrangements in which the risk for out-of-plan covered services is borne through reinsurance. The term also includes indemnity benefits that are underwritten in whole by a licensed insurance carrier or a self-funded employer group. For purposes of this Section, "out-of-plan services" means those services which are obtained from providers who do not have a contract, or any other arrangements, with a managed care dental plan or services obtained without a referral from providers who have contracted to provide services to the enrollees on behalf of the managed care dental plan.

"Primary care provider (dentist)" means a dentist, having an arrangement with a managed care dental plan, selected by an enrollee or assigned to an enrollee by a plan to provide dental care services under a managed care dental plan.

"Prospective enrollee" means an individual eligible for enrollment in a managed care dental plan offered by that individual's employer.

"Provider" means either a general dentist or a dentist who is a licensed specialist.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/15)

Sec. 15. Rules. The Department may promulgate such rules as it deems reasonably necessary to implement the terms of this Act. The Department shall establish an advisory committee made up of representatives from the dental profession to provide clinical advice and counsel to the Department regarding dental managed care issues for which a dentist's professional training is relevant in the course of administering this Act. The advisory committee shall be comprised of dentists licensed to practice in Illinois, appointed by the Director as follows: 2 dental directors or their dentist designee from managed care dental plans which are subject to this Act, 2 general dentists, and the dental director of the Illinois Department of Public Health. The advisory committee shall meet as reasonably determined by the Director. Nothing in this Section shall be deemed as authorizing or permitting the Department to delegate any authority to enforce the provisions of this Act to the advisory committee and any such delegation is expressly prohibited hereunder.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/25)

Sec. 25. Provision of information.

(a) A managed care dental plan shall provide upon request to prospective enrollees a written summary description of all of the following terms of coverage:

(1) Information about the dental plan, including how the plan operates and what general types of financial arrangements exist between dentists and the plan. Nothing in this Section shall require disclosure of any specific financial arrangements between providers and the plan.
(2) The service area.
(3) Covered benefits, exclusions, or limitations.
(4) Pre-certification requirements including any requirements for referrals made by primary care dentists to specialists, and other preauthorization requirements.
(5) A list of participating primary care dentists in the plan's service area, including provider address and phone number, for an enrollee to evaluate the managed care dental plan's network access, as well as a phone number by which the prospective enrollee may obtain additional information regarding the provider network including participating specialists. However, a managed care dental plan offering a preferred provider organization ("PPO") product that does not require the enrollee to select a primary care dentist shall only be required to make available for inspection to enrollees and prospective enrollees a list of participating dentists in the plan's service area, including whether the provider is accepting new patients at each of the specific locations listing the provider. Providers shall notify managed care dental plans electronically or in writing of any changes to their information as listed in the provider directory. Managed care dental plans shall update their directories in a manner consistent with the information provided by the provider or dental management service organization within 10 business days after being notified of the change by the provider.
Nothing in this paragraph (5) shall void any contractual relationship between the provider and the plan.
(6) Emergency coverage and benefits.
(7) Out-of-area coverages and benefits, if any.
(8) The process about how participating dentists are selected.
(9) The grievance process, including the telephone number to call to receive information concerning grievance procedures.

An enrollee shall be provided with an evidence of coverage as required under the Illinois Insurance Code provisions applicable to the managed care dental plan.

(b) An enrollee or prospective enrollee has the right to the most current financial statement filed by the managed care dental plan by contacting the Department of Insurance. The Department may charge a reasonable fee for providing such information.

(c) The managed care dental plan shall provide to the Department, on an annual basis, a list of all participating dentists. Nothing in this Section shall require a particular ratio for any type of provider.

(d) If the managed care dental plan uses a capitation method of compensation to its primary care providers (dentists), the plan must establish and follow procedures that ensure that:

(1) the plan application form includes a space in which each enrollee selects a primary care provider (dentist);
(2) if an enrollee who fails to select a primary care provider (dentist) is assigned a primary care provider (dentist), the enrollee shall be notified of the name and location of that primary care provider (dentist); and
(3) primary care provider (dentist) to whom an enrollee is assigned, pursuant to item (2), is physically located within a reasonable travel distance, as established by rule adopted by the Director, from the residence or place of employment of the enrollee.

(e) Nothing in this Act shall be deemed to require a plan to assign an enrollee to a primary care provider (dentist).

(Source: P.A. 99-329, eff. 1-1-16.)

(215 ILCS 109/35)

Sec. 35. Credentialing; utilization review; provider input.

(a) Participating dentists shall be given an opportunity to comment on the plan's policies affecting their services to include the plan's dental policy, including coverage of a new technology and procedures, utilization review criteria and procedures, quality and credentialing criteria, and dental management procedures provided, however, a plan shall not be required to release any information which it deems confidential or proprietary.

(b) Upon request, managed care dental plans shall disclose to prospective purchasers the process about how participating dentists are selected for the plan.

(c) A dentist under consideration for inclusion in a managed care dental plan that requires the enrollee to select a primary care provider (dentist) shall be subject to the managed care dental plan's credentialing policy, which shall be overseen by the dental director of the managed care dental plan.

(d) Credentialing of dentists who will participate in a managed care dental plan that requires its enrollees to select a primary care provider (dentist) shall be based on identified guidelines that have been adopted by the plan. The managed care dental plan shall make the credentialing guidelines available to applicants, upon request.

(e) A managed care dental plan shall have a dental director who is a licensed dentist. The dental director shall ultimately be responsible for the benefit coverage decisions made by the plan which require professional dental training and clinical judgement. Decisions made by the plan to deny coverage for a procedure, based primarily upon clinical judgment, or that a payment for an alternative procedure should be considered must be made by the dental director or a licensed dentist acting under the supervision of the dental director. Nothing in this Section prohibits a benefit coverage decision that does not require a dentist's professional judgment from being denied without a dentist's involvement.

A provider advocating on behalf of a patient who has had a claim denied, the basis of which requires professional dental training and judgment, or was offered an alternative benefit for payment by the plan has an opportunity to appeal to the dental director by submitting a written appeal and providing information that is reasonably needed to consider the appeal. The dental director or a licensed dentist acting under the supervision of the dental director shall respond to the provider's appeal. Enrollees shall be afforded appeal rights as specified in the benefits contract or as otherwise provided by law.

(h) A managed care dental plan may not exclude a provider solely because of the anticipated characteristics of the patients of that provider.

(i) Before terminating a contract with a provider for cause, the managed care dental plan shall provide a written explanation of the reasons for termination. The provider shall be given an opportunity for discussion with the dental director or his dentist designee. If a managed care dental plan conducts or uses utilization profiling as the primary basis for terminating the provider contract for cause, the managed care dental plan shall make available the utilization data relevant to that provider in advance of the termination.

(j) A communication relating to the subject matter provided for under subsection (a) or (i) of this Section may not be the basis for a cause of action for libel or slander, except for disclosures or communications with parties other than the plan or provider.

(k) The managed care dental plan shall establish reasonable procedures for assuring a transition of enrollees of the plan to new providers.

(l) This Act does not prohibit a managed care dental plan from rejecting an application from a provider based on the plan's determination that the plan has sufficient qualified providers or if the plan reasonably determines that inclusion of the provider is not in the best interest of the managed care dental plan and its enrollees. Nothing in this Act shall be construed as requiring a managed care dental plan to contract with a dentist who has not agreed to the terms of participation as specified by the plan.

(m) No contractual provision shall in any way prohibit a dentist from discussing all clinical options for treatment with a patient.

(n) A managed care dental plan shall submit for the Director's approval, and thereafter maintain, a system for the resolution of grievances concerning the provision of dental care services or other matters concerning operation of the managed care dental plan.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/40)

Sec. 40. Coverage; prior authorization. A managed care dental plan shall:

(1) cover palliative treatment for emergency dental services, as included in its certificate of coverage, without regard to whether the provider furnishing the services has a contractual or other arrangement with the entity to provide items or services to covered individuals, provided that the enrollee has made a reasonable attempt to first obtain service through the appropriate primary care dentist; and
(2) if an enrollee suffers trauma to the mouth, teeth or oral cavity that results in a need for emergency dental services, as included in the certificate of coverage, provide that the prior authorization requirement for emergency dental is waived.

Nothing in this Section shall be deemed as requiring managed care dental plans to provide coverage for emergency dental services in excess of that required in the Illinois Insurance Code.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/45)

Sec. 45. Prior authorization; consent forms. A plan for which prior authorization is a condition to coverage of a service must clearly disclose this provision in the evidence of coverage.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/50)

Sec. 50. Point-of-service plans.

(a) If an employer who has 25 or more employees and contributes 25% or more to the cost of the dental benefit plan coverage to employees and the only dental plan coverage being offered requires enrollees to select a primary care provider (dentist) and has no out-of-plan covered services option, the managed care dental plan with which the employer is contracting for the coverage shall offer a dental point-of-service ("POS") option to the employee.

(b) An employer may require an employee who accepts the POS option to be responsible for the payment of a premium over the amount of the premium for the coverage provided to employees under the dental benefit plan offered which requires enrollees to select a primary care provider (dentist) and has no out-of-plan covered services option. The enrollee may pay any additional premium either directly or by payroll deduction in the same manner in which the other premium is paid. The premium for the POS option shall be as established by the managed care dental plan using its underwriting guidelines for establishing rates to be charged for products which it offers.

(d) An employer may charge an employee who accepts the POS option a reasonable administrative fee for costs associated with the employer's reasonable administration of the POS option.

(e) The POS option to be offered pursuant to this Section may be satisfied by the plan by allowing prospective enrollees to elect the POS option during the employer's enrollment period, and remaining in the POS option until the next open enrollment period, or any other basis reasonably determined by the plan to satisfy the requirements of this Section.

(f) A managed care dental plan required to offer a POS option pursuant to this Act shall be subject to those rules for POS products as set by the Department.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/55)

Sec. 55. Private cause of action; existing remedies. This Act and rules adopted under this Act do not:

(1) provide a private cause of action for damages or create a standard of care, obligation, or duty that provides a basis for a private cause of action for damages; or
(2) abrogate a statutory or common law cause of action, administrative remedy, or defense otherwise available and existing before the effective date of this Act.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/60)

Sec. 60. Record of complaints.

(a) The Department shall maintain records concerning the complaints filed against the plan with the Department. The Department shall make a summary of all data collected available upon request and publish the summary on the World Wide Web.

(b) The Department shall maintain records on the number of complaints filed against each plan.

(1) a consumer or enrollee;
(2) a provider; or
(3) any other individual.

(d) (Blank).

(e) The Department shall maintain records classifying each complaint according to the nature of the complaint as it pertains to a specific function of the plan. The complaints shall be classified under the following categories:

(1) denial of care or treatment;
(2) denial of a diagnostic procedure;
(3) denial of a referral request;
(4) sufficient choice and accessibility of dentists;
(5) underwriting;
(6) marketing and sales;
(7) claims and utilization review;
(8) member services;
(9) provider relations; and
(10) miscellaneous.

(f) The Department shall maintain records classifying the disposition of each complaint. The disposition of the complaint shall be classified in one of the following categories:

(1) complaint referred to the plan and no further action necessary by the Department;
(2) no corrective action deemed necessary by the Department; or
(3) corrective action taken by the Department.

(g) No Department publication or release of information shall identify any enrollee, dentist, or individual complainant.

(Source: P.A. 91-355, eff. 1-1-00; 92-16, eff. 6-28-01.)

(215 ILCS 109/65)

Sec. 65. Administration of Act. The Director may adopt rules necessary to implement the Department's responsibility under this Act. To enforce the provisions of this Act, the director may issue a cease and desist order or require a managed care dental plan to submit a plan of correction for violations of this Act, or both. Subject to the provisions of the Illinois Administrative Procedure Act, the Director may impose an administrative fine, not to exceed $1,000, for failure to submit a requested plan of correction, failure to comply with its plan of correction, or repeated violations of the Act. All final decisions regarding the imposition of a fine shall be subject to review under the Illinois Administrative Review Law.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/70)

Sec. 70. Retaliation prohibited. A managed care dental plan may not take any retaliatory actions, including cancellation or refusal to renew a policy, against an employer or enrollee solely because the employer or enrollee has filed complaints with the plan or appealed a decision of the plan.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/75)

Sec. 75. Application of other law.

(a) All provisions of this Act and other applicable law that are not in conflict with this Act shall apply to managed care dental plans and other persons subject to this Act.

(b) Solicitation of enrollees by a managed care entity granted a certificate of authority or its representatives shall not be construed to violate any provision of law relating to solicitation or advertising by health professionals.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/80)

Sec. 80. Limitations on indemnification provisions. No contract between a managed care dental plan and a provider may require that the provider indemnify the managed care dental plan for the Plan's, or its officers, employees, or agents, negligence, willful misconduct, or breach of contract, if any, provided nothing herein shall relieve the provider for such obligations that have been delegated to the provider pursuant to written agreement. The delegation of functions agreed to between the plan and the provider shall be identified in the written agreement.

(Source: P.A. 91-355, eff. 1-1-00.)

(215 ILCS 109/85)

Sec. 85. Severability. The provisions of this Act are severable under Section 1.31 of the Statute on Statutes.

(Source: P.A. 91-355, eff. 1-1-00.)

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