2023 Illinois Compiled Statutes › Chapter 215 - INSURANCE › 215 ILCS 109/ - Dental Care Patient Protection Act.

(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.
(c) Different cost-sharing provisions may be imposed for the POS
option.
(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.
(c) The Department shall maintain records classifying each complaint by
whether the complaint was filed by:
(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.)