Bill Amendment: IL SB0750 | 2015-2016 | 99th General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

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Bill Title: INSURANCE-DENTAL SERVICE PLANS

Status: 2015-08-10 - Public Act . . . . . . . . . 99-0329 [SB0750 Detail]

Download: Illinois-2015-SB0750-Senate_Amendment_003.html

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Sen. Michael E. Hastings

Filed: 4/17/2015

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AMENDMENT TO SENATE BILL 750
AMENDMENT NO. ______. Amend Senate Bill 750, AS AMENDED, by
replacing everything after the enacting clause with:
"Section 5. The Illinois Insurance Code is amended by
changing Section 355a as follows:
(215 ILCS 5/355a) (from Ch. 73, par. 967a)
Sec. 355a. Standardization of terms and coverage.
(1) The purpose of this Section shall be (a) to provide
reasonable standardization and simplification of terms and
coverages of individual accident and health insurance policies
to facilitate public understanding and comparisons; (b) to
eliminate provisions contained in individual accident and
health insurance policies which may be misleading or
unreasonably confusing in connection either with the purchase
of such coverages or with the settlement of claims; and (c) to
provide for reasonable disclosure in the sale of accident and

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health coverages.
(2) Definitions applicable to this Section are as follows:
(a) "Policy" means all or any part of the forms
constituting the contract between the insurer and the
insured, including the policy, certificate, subscriber
contract, riders, endorsements, and the application if
attached, which are subject to filing with and approval by
the Director.
(b) "Service corporations" means voluntary health and
dental corporations organized and operating respectively
under the Voluntary Health Services Plans Act and the
Dental Service Plan Act.
(c) "Accident and health insurance" means insurance
written under Article XX of the Insurance Code, other than
credit accident and health insurance, and coverages
provided in subscriber contracts issued by service
corporations. For purposes of this Section such service
corporations shall be deemed to be insurers engaged in the
business of insurance.
(3) The Director shall issue such rules as he shall deem
necessary or desirable to establish specific standards,
including standards of full and fair disclosure that set forth
the form and content and required disclosure for sale, of
individual policies of accident and health insurance, which
rules and regulations shall be in addition to and in accordance
with the applicable laws of this State, and which may cover but

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shall not be limited to: (a) terms of renewability; (b) initial
and subsequent conditions of eligibility; (c) non-duplication
of coverage provisions; (d) coverage of dependents; (e)
pre-existing conditions; (f) termination of insurance; (g)
probationary periods; (h) limitation, exceptions, and
reductions; (i) elimination periods; (j) requirements
regarding replacements; (k) recurrent conditions; and (l) the
definition of terms including but not limited to the following:
hospital, accident, sickness, injury, physician, accidental
means, total disability, partial disability, nervous disorder,
guaranteed renewable, and non-cancellable.
The Director may issue rules that specify prohibited policy
provisions not otherwise specifically authorized by statute
which in the opinion of the Director are unjust, unfair or
unfairly discriminatory to the policyholder, any person
insured under the policy, or beneficiary.
(4) The Director shall issue such rules as he shall deem
necessary or desirable to establish minimum standards for
benefits under each category of coverage in individual accident
and health policies, other than conversion policies issued
pursuant to a contractual conversion privilege under a group
policy, including but not limited to the following categories:
(a) basic hospital expense coverage; (b) basic
medical-surgical expense coverage; (c) hospital confinement
indemnity coverage; (d) major medical expense coverage; (e)
disability income protection coverage; (f) accident only

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coverage; and (g) specified disease or specified accident
coverage.
Nothing in this subsection (4) shall preclude the issuance
of any policy which combines two or more of the categories of
coverage enumerated in subparagraphs (a) through (f) of this
subsection.
No policy shall be delivered or issued for delivery in this
State which does not meet the prescribed minimum standards for
the categories of coverage listed in this subsection unless the
Director finds that such policy is necessary to meet specific
needs of individuals or groups and such individuals or groups
will be adequately informed that such policy does not meet the
prescribed minimum standards, and such policy meets the
requirement that the benefits provided therein are reasonable
in relation to the premium charged. The standards and criteria
to be used by the Director in approving such policies shall be
included in the rules required under this Section with as much
specificity as practicable.
The Director shall prescribe by rule the method of
identification of policies based upon coverages provided.
(5) (a) In order to provide for full and fair disclosure in
the sale of individual accident and health insurance policies,
no such policy shall be delivered or issued for delivery in
this State unless the outline of coverage described in
paragraph (b) of this subsection either accompanies the policy,
or is delivered to the applicant at the time the application is

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made, and an acknowledgment signed by the insured, of receipt
of delivery of such outline, is provided to the insurer. In the
event the policy is issued on a basis other than that applied
for, the outline of coverage properly describing the policy
must accompany the policy when it is delivered and such outline
shall clearly state that the policy differs, and to what
extent, from that for which application was originally made.
All policies, except single premium nonrenewal policies, shall
have a notice prominently printed on the first page of the
policy or attached thereto stating in substance, that the
policyholder shall have the right to return the policy within
10 days of its delivery and to have the premium refunded if
after examination of the policy the policyholder is not
satisfied for any reason.
(b) The Director shall issue such rules as he shall deem
necessary or desirable to prescribe the format and content of
the outline of coverage required by paragraph (a) of this
subsection. "Format" means style, arrangement, and overall
appearance, including such items as the size, color, and
prominence of type and the arrangement of text and captions.
"Content" shall include without limitation thereto, statements
relating to the particular policy as to the applicable category
of coverage prescribed under subsection 4; principal benefits;
exceptions, reductions and limitations; and renewal
provisions, including any reservation by the insurer of a right
to change premiums. Such outline of coverage shall clearly

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state that it constitutes a summary of the policy issued or
applied for and that the policy should be consulted to
determine governing contractual provisions.
(c) Without limiting the generality of paragraph (b) of
this subsection (5), no qualified health plans shall be offered
for sale directly to consumers through the health insurance
marketplace operating in the State in accordance with Sections
1311 and 1321 of the federal Patient Protection and Affordable
Care Act of 2010 (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any amendments thereto, or
regulations or guidance issued thereunder (collectively, "the
Federal Act"), unless the following information is made
available to the consumer at the time he or she is comparing
policies and their premiums:
(i) With respect to prescription drug benefits, the
most recently published formulary where a consumer can view
in one location covered prescription drugs; information on
tiering and the cost-sharing structure for each tier; and
information about how a consumer can obtain specific
copayment amounts or coinsurance percentages for a
specific qualified health plan before enrolling in that
plan. This information shall clearly identify the
qualified health plan to which it applies.
(ii) The most recently published provider directory
where a consumer can view the provider network that applies

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to each qualified health plan and information about each
provider, including location, contact information,
specialty, medical group, if any, any institutional
affiliation, and whether the provider is accepting new
patients at each of the specific locations listing the
provider. Providers shall notify qualified health plans
electronically or in writing of any changes to their
information as listed in the provider directory. Qualified
health plans shall update their directories in a manner
consistent with the information provided by the provider
within 10 business days after being notified of the change
by the provider. Nothing in this paragraph (ii) shall void
any contractual relationship between the provider and the
plan. The information shall clearly identify the qualified
health plan to which it applies.
(d) Each company that offers qualified health plans for
sale directly to consumers through the health insurance
marketplace operating in the State shall make the information
in paragraph (c) of this subsection (5), for each qualified
health plan that it offers, available and accessible to the
general public on the company's Internet website and through
other means for individuals without access to the Internet.
(e) The Department shall ensure that State-operated
Internet websites, in addition to the Internet website for the
health insurance marketplace established in this State in
accordance with the Federal Act, prominently provide links to

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Internet-based materials and tools to help consumers be
informed purchasers of health insurance.
(f) Nothing in this Section shall be interpreted or
implemented in a manner not consistent with the Federal Act.
This Section shall apply to all qualified health plans offered
for sale directly to consumers through the health insurance
marketplace operating in this State for any coverage year
beginning on or after January 1, 2015.
(6) Prior to the issuance of rules pursuant to this
Section, the Director shall afford the public, including the
companies affected thereby, reasonable opportunity for
comment. Such rulemaking is subject to the provisions of the
Illinois Administrative Procedure Act.
(7) When a rule has been adopted, pursuant to this Section,
all policies of insurance or subscriber contracts which are not
in compliance with such rule shall, when so provided in such
rule, be deemed to be disapproved as of a date specified in
such rule not less than 120 days following its effective date,
without any further or additional notice other than the
adoption of the rule.
(8) When a rule adopted pursuant to this Section so
provides, a policy of insurance or subscriber contract which
does not comply with the rule shall not less than 120 days from
the effective date of such rule, be construed, and the insurer
or service corporation shall be liable, as if the policy or
contract did comply with the rule.

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(9) Violation of any rule adopted pursuant to this Section
shall be a violation of the insurance law for purposes of
Sections 370 and 446 of the Insurance Code.
(Source: P.A. 98-1035, eff. 8-25-14.)
Section 10. The Dental Care Patient Protection Act is
amended by changing Section 25 as follows:
(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

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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 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

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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

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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. 91-355, eff. 1-1-00.)
Section 15. The Illinois Dental Practice Act is amended by
changing Sections 44 and 45 as follows:
(225 ILCS 25/44) (from Ch. 111, par. 2344)
(Section scheduled to be repealed on January 1, 2016)
Sec. 44. Practice by Corporations Prohibited. Exceptions.
No corporation shall practice dentistry or engage therein, or
hold itself out as being entitled to practice dentistry, or
furnish dental services or dentists, or advertise under or
assume the title of dentist or dental surgeon or equivalent
title, or furnish dental advice for any compensation, or
advertise or hold itself out with any other person or alone,
that it has or owns a dental office or can furnish dental
service or dentists, or solicit through itself, or its agents,
officers, employees, directors or trustees, dental patronage
for any dentist employed by any corporation.
Nothing contained in this Act, however, shall:
(a) prohibit a corporation from employing a dentist or
dentists to render dental services to its employees,

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provided that such dental services shall be rendered at no
cost or charge to the employees;
(b) prohibit a corporation or association from
providing dental services upon a wholly charitable basis to
deserving recipients;
(c) prohibit a corporation or association from
furnishing information or clerical services which can be
furnished by persons not licensed to practice dentistry, to
any dentist when such dentist assumes full responsibility
for such information or services;
(d) prohibit dental corporations as authorized by the
Professional Service Corporation Act, dental associations
as authorized by the Professional Association Act, or
dental limited liability companies as authorized by the
Limited Liability Company Act;
(e) prohibit dental limited liability partnerships as
authorized by the Uniform Partnership Act (1997);
(f) prohibit hospitals, public health clinics,
federally qualified health centers, or other entities
specified by rule of the Department from providing dental
services; or
(g) prohibit dental management service organizations
from providing non-clinical business services that do not
violate the provisions of this Act.
Any corporation violating the provisions of this Section is
guilty of a Class A misdemeanor and each day that this Act is

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violated shall be considered a separate offense.
If a dental management service organization is responsible
for enrolling the dentist as a provider in managed care plans
provider networks, it shall provide verification to the managed
care provider network regarding whether the provider is
accepting new patients at each of the specific locations
listing the provider.
Nothing in this Section shall void any contractual
relationship between the provider and the organization.
(Source: P.A. 96-328, eff. 8-11-09.)
(225 ILCS 25/45) (from Ch. 111, par. 2345)
(Section scheduled to be repealed on January 1, 2016)
Sec. 45. Advertising. The purpose of this Section is to
authorize and regulate the advertisement by dentists of
information which is intended to provide the public with a
sufficient basis upon which to make an informed selection of
dentists while protecting the public from false or misleading
advertisements which would detract from the fair and rational
selection process.
Any dentist may advertise the availability of dental
services in the public media or on the premises where such
dental services are rendered. Such advertising shall be limited
to the following information:
(a) The dental services available;
(b) Publication of the dentist's name, title, office

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hours, address and telephone;
(c) Information pertaining to his or her area of
specialization, including appropriate board certification
or limitation of professional practice;
(d) Information on usual and customary fees for routine
dental services offered, which information shall include
notification that fees may be adjusted due to complications
or unforeseen circumstances;
(e) Announcement of the opening of, change of, absence
from, or return to business;
(f) Announcement of additions to or deletions from
professional dental staff;
(g) The issuance of business or appointment cards;
(h) Other information about the dentist, dentist's
practice or the types of dental services which the dentist
offers to perform which a reasonable person might regard as
relevant in determining whether to seek the dentist's
services. However, any advertisement which announces the
availability of endodontics, pediatric dentistry,
periodontics, prosthodontics, orthodontics and dentofacial
orthopedics, oral and maxillofacial surgery, or oral and
maxillofacial radiology by a general dentist or by a
licensed specialist who is not licensed in that specialty
shall include a disclaimer stating that the dentist does
not hold a license in that specialty.
Any dental practice with more than one location that

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enrolls its dentist as a participating provider in a managed
care plan's network must verify electronically or in writing to
the managed care plan whether the provider is accepting new
patients at each of the specific locations listing the
provider. The health plan shall remove the provider from the
directory in accordance with standard practices within 10
business days after being notified of the changes by the
provider. Nothing in this paragraph shall void any contractual
relationship between the provider and the plan.
It is unlawful for any dentist licensed under this Act to
do any of the following:
(1) Use claims of superior quality of care to entice
the public.
(2) Advertise in any way to practice dentistry without
causing pain.
(3) Pay a fee to any dental referral service or other
third party who advertises a dental referral service,
unless all advertising of the dental referral service makes
it clear that dentists are paying a fee for that referral
service.
(4) Advertise or offer gifts as an inducement to secure
dental patronage. Dentists may advertise or offer free
examinations or free dental services; it shall be unlawful,
however, for any dentist to charge a fee to any new patient
for any dental service provided at the time that such free
examination or free dental services are provided.

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(5) Use the term "sedation dentistry" or similar terms
in advertising unless the advertising dentist holds a valid
and current permit issued by the Department to administer
either general anesthesia, deep sedation, or conscious
sedation as required under Section 8.1 of this Act.
This Act does not authorize the advertising of dental
services when the offeror of such services is not a dentist.
Nor shall the dentist use statements which contain false,
fraudulent, deceptive or misleading material or guarantees of
success, statements which play upon the vanity or fears of the
public, or statements which promote or produce unfair
competition.
A dentist shall be required to keep a copy of all
advertisements for a period of 3 years. All advertisements in
the dentist's possession shall indicate the accurate date and
place of publication.
The Department shall adopt rules to carry out the intent of
this Section.
(Source: P.A. 97-1013, eff. 8-17-12.)
Section 99. Effective date. This Act takes effect January
1, 2016.".