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| Public Act 099-0329
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| SB0750 Enrolled | LRB099 04042 MLM 24060 b |
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AN ACT concerning regulation.
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Be it enacted by the People of the State of Illinois,
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represented in the General Assembly:
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Section 5. The Illinois Insurance Code is amended by |
changing Section 355a as follows:
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(215 ILCS 5/355a) (from Ch. 73, par. 967a)
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Sec. 355a. Standardization of terms and coverage.
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(1) The purpose of this Section shall be (a) to provide
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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
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provide for reasonable disclosure in the sale of accident and |
health
coverages.
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(2) Definitions applicable to this Section are as follows:
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(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 |
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the Director.
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(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.
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(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
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corporations shall be deemed to be insurers engaged in the |
business of
insurance.
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(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 |
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 |
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definition of terms including but not limited to the following:
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hospital, accident, sickness, injury, physician, accidental |
means, total
disability, partial disability, nervous disorder, |
guaranteed renewable,
and non-cancellable.
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The Director may issue rules that specify prohibited policy
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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.
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(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
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medical-surgical expense coverage; (c) hospital confinement |
indemnity
coverage; (d) major medical expense coverage; (e) |
disability income
protection coverage; (f) accident only |
coverage; and (g) specified
disease or specified accident |
coverage.
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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.
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No policy shall be delivered or issued for delivery in this |
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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
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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.
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The Director shall prescribe by rule the method of |
identification of
policies based upon coverages provided.
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(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 |
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. |
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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.
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(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;
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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 |
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.
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(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 |
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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 |
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. Dental providers shall notify qualified health |
plans electronically or in writing of any changes to their |
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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 or |
dental management service organization 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 |
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 |
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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.
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(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.
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(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.
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(Source: P.A. 98-1035, eff. 8-25-14.)
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Section 10. The Dental Care Patient Protection Act is |
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amended by changing Section 25 as follows:
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(215 ILCS 109/25)
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Sec. 25. Provision of information.
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(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:
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(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
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financial arrangements between providers and the plan.
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(2) The service area.
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(3) Covered benefits, exclusions, or limitations.
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(4) Pre-certification requirements including any |
requirements for
referrals
made by primary care dentists to |
specialists, and other preauthorization
requirements.
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(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
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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 |
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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
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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.
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(6) Emergency coverage and benefits.
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(7) Out-of-area coverages and benefits, if any.
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(8) The process about how participating dentists are |
selected.
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(9) The grievance process, including the telephone |
number to call to
receive information concerning grievance |
procedures.
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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.
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(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.
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(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.
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(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:
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(1) the plan application form includes a space in which |
each enrollee
selects a primary care provider (dentist);
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(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
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(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.
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(e) Nothing in this Act shall be deemed to require a plan |
to assign an
enrollee to a primary care provider (dentist).
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(Source: P.A. 91-355, eff. 1-1-00.)
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Section 15. The Illinois Dental Practice Act is amended by |
changing Sections 44 and 45 as follows:
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(225 ILCS 25/44) (from Ch. 111, par. 2344)
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(Section scheduled to be repealed on January 1, 2016)
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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
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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.
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Nothing contained in this Act, however, shall:
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(a) prohibit a corporation from employing a dentist or |
dentists to render
dental services to its employees, |
provided that such dental services shall
be rendered at no |
cost or charge to the employees;
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(b) prohibit a corporation or association from |
providing dental services
upon a wholly charitable basis to |
deserving recipients;
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(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;
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(d) prohibit dental corporations as authorized by the
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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;
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(e) prohibit dental limited liability partnerships as |
authorized by the
Uniform Partnership Act (1997);
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(f) prohibit hospitals, public health clinics, |
federally qualified
health centers, or other entities |
specified by rule of the Department from
providing dental |
services; or
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(g) prohibit dental management service organizations |
from providing
non-clinical business services that do not |
violate the provisions of this
Act.
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Any corporation violating the provisions of this Section is |
guilty of a
Class A misdemeanor and each day that this Act is |
violated shall be
considered a separate offense.
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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 |
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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.)
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(225 ILCS 25/45) (from Ch. 111, par. 2345)
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(Section scheduled to be repealed on January 1, 2016)
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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
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advertisements which would detract from the fair and rational |
selection
process.
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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:
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(a) The dental services available;
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(b) Publication of the dentist's name, title, office |
hours, address
and telephone;
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(c) Information pertaining to his or her area of |
specialization, including
appropriate board certification |
or limitation of professional practice;
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(d) Information on usual and customary fees for routine |
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dental services
offered, which information shall include |
notification that fees may be
adjusted due to complications |
or unforeseen circumstances;
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(e) Announcement of the opening of, change of, absence |
from, or return
to business;
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(f) Announcement of additions to or deletions from |
professional
dental staff;
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(g) The issuance of business or appointment cards;
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(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
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availability of endodontics, pediatric dentistry,
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periodontics, prosthodontics, orthodontics and dentofacial |
orthopedics,
oral and maxillofacial
surgery, or oral and |
maxillofacial radiology by a general dentist or by a
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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.
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Any dental practice with more than one location that |
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 |
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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:
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(1) Use claims of superior quality of care to
entice |
the public.
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(2) Advertise in any way to practice dentistry without |
causing pain.
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(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.
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(4) Advertise or offer gifts as an inducement to secure
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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
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examination or free dental services are provided. |
(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.
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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.
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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.
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The Department shall adopt rules to carry out the intent of |
this Section.
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(Source: P.A. 97-1013, eff. 8-17-12.)
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