Bill Amendment: IL SB1289 | 2023-2024 | 103rd General Assembly
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: INS-DENTAL CARE/REIMBURSEMENT
Status: 2024-07-18 - Public Act . . . . . . . . . 103-0651 [SB1289 Detail]
Download: Illinois-2023-SB1289-House_Amendment_001.html
Bill Title: INS-DENTAL CARE/REIMBURSEMENT
Status: 2024-07-18 - Public Act . . . . . . . . . 103-0651 [SB1289 Detail]
Download: Illinois-2023-SB1289-House_Amendment_001.html
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1 | AMENDMENT TO SENATE BILL 1289
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2 | AMENDMENT NO. ______. Amend Senate Bill 1289 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 1. Short title. This Act may be referred to as the | ||||||
5 | Dental Loss Ratio Act.
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6 | Section 5. Definitions. As used in this Act: | ||||||
7 | "Dental care provider" means a dentist who bills for | ||||||
8 | services in Illinois. | ||||||
9 | "Dental loss ratio" means the ratio of incurred claims to | ||||||
10 | earned premiums as calculated using the formula under Section | ||||||
11 | 10 of this Act. | ||||||
12 | "Dental plan carrier" means an entity subject to the | ||||||
13 | insurance laws, rules, and regulations of this State or | ||||||
14 | subject to the jurisdiction of the Director that contracts or | ||||||
15 | offers to contract to provide, deliver, arrange for, pay for, | ||||||
16 | or reimburse any of the costs of dental care services, |
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1 | including an accident and health insurance company, a health | ||||||
2 | maintenance organization, a limited health service | ||||||
3 | organization, a dental service plan corporation, a health | ||||||
4 | services plan corporation, a voluntary health services plan, | ||||||
5 | or any other entity providing a plan of dental insurance, | ||||||
6 | dental benefits, or dental health care services. | ||||||
7 | "Department" means the Department of Insurance. | ||||||
8 | "Director" means the Director of Insurance. | ||||||
9 | "Earned premiums" means the portion of the premium paid in | ||||||
10 | the reporting year that is intended to provide coverage during | ||||||
11 | that reporting period. | ||||||
12 | "Incurred claims" means the claims for which services were | ||||||
13 | provided in that reporting year. "Incurred claims" includes | ||||||
14 | claims that were paid in the reporting year plus unpaid claim | ||||||
15 | reserves for claims paid after the reporting year.
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16 | Section 10. Dental loss ratio reporting. | ||||||
17 | (a) A health insurer or dental plan carrier that issues, | ||||||
18 | sells, renews, or offers a specialized health insurance policy | ||||||
19 | covering dental services shall, beginning January 1, 2024, | ||||||
20 | annually submit to the Department the dental loss ratio | ||||||
21 | calculated in accordance with subsection (c). The annual | ||||||
22 | filing shall, at a minimum, include rates, rating schedules, | ||||||
23 | and supporting documentation, including ratios of incurred | ||||||
24 | claims to earned premiums for each calendar year since the | ||||||
25 | plan's issuance. The required information shall be in the form |
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1 | established by the Department and shall demonstrate that each | ||||||
2 | plan complies with the minimum dental loss ratio standards. | ||||||
3 | (b) The annual filing shall be made publicly available on | ||||||
4 | the Department's website. | ||||||
5 | (c) The dental loss ratio for a dental plan or dental | ||||||
6 | coverage of a health benefit plan shall be determined by | ||||||
7 | dividing the numerator by the denominator as follows: | ||||||
8 | (1) The numerator is the amount spent on dental care. | ||||||
9 | The amount spent on dental care shall include: | ||||||
10 | (A) the amount expended for clinical dental | ||||||
11 | services that are services within the Code on Dental | ||||||
12 | Procedures and Nomenclature, provided to enrollees | ||||||
13 | that includes payments under capitation contracts with | ||||||
14 | dental providers, and covered by the contract for | ||||||
15 | dental clinical services or supplies covered by the | ||||||
16 | contract; | ||||||
17 | (B) reserves and liabilities established to | ||||||
18 | account for claims that were incurred during the | ||||||
19 | reporting year but were not paid within 3 months of the | ||||||
20 | end of the reporting year; and | ||||||
21 | (C) any claim payment recovered by insurers from | ||||||
22 | providers or enrollees using utilization management | ||||||
23 | efforts, but which shall be deducted from incurred | ||||||
24 | claims amounts. | ||||||
25 | (2) The calculation of the numerator does not include: | ||||||
26 | (A) any overpayment that has already been received |
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1 | from providers that should not be reported as a paid | ||||||
2 | claim; overpayment recoveries received from providers | ||||||
3 | must be deducted from incurred claims amounts; | ||||||
4 | (B) all administrative costs, including, but not | ||||||
5 | limited to, infrastructure, personnel costs, or broker | ||||||
6 | payments; | ||||||
7 | (C) amounts paid to third-party vendors for | ||||||
8 | secondary network savings; | ||||||
9 | (D) amounts paid to third-party vendors for | ||||||
10 | network development, administrative fees, claims | ||||||
11 | processing, and utilization management; or | ||||||
12 | (E) amounts paid to providers for professional or | ||||||
13 | administrative services that do not represent | ||||||
14 | compensation or reimbursement for covered services | ||||||
15 | provided to an enrollee, including, but not limited | ||||||
16 | to, dental record copying costs, attorney's fees, | ||||||
17 | subrogation vendor fees, compensation to | ||||||
18 | paraprofessionals, janitors, quality assurance | ||||||
19 | analysts, administrative supervisors, secretaries to | ||||||
20 | dental personnel, and dental record clerks. | ||||||
21 | (3) The denominator is the total amount of the earned | ||||||
22 | premium revenues, excluding federal and State taxes and | ||||||
23 | licensing and regulatory fees paid after accounting for | ||||||
24 | any payments pursuant to federal law. In this paragraph, | ||||||
25 | "earned premium revenues" means all moneys paid by a | ||||||
26 | policyholder or subscriber as a condition of receiving |
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1 | coverage from the issuer, including any fees or other | ||||||
2 | contributions associated with the dental plan. | ||||||
3 | (d) If the Director decides to conduct an examination | ||||||
4 | because the Director finds it necessary to verify a health | ||||||
5 | insurer's or dental plan carrier's representation in a dental | ||||||
6 | loss ratio report, then the Department shall provide the | ||||||
7 | health insurer or dental plan carrier with a notification 30 | ||||||
8 | days before the commencement of the examination. | ||||||
9 | (e) The health insurer or dental plan carrier shall have | ||||||
10 | 30 days after the date of notification to electronically | ||||||
11 | submit to the Department all requested records specified by | ||||||
12 | the Department. The Director may extend the time for a health | ||||||
13 | insurer or dental plan carrier to comply with this examination | ||||||
14 | upon a finding of good cause.
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15 | Section 15. Dental loss ratio requirement. | ||||||
16 | (a) A health insurer or dental plan carrier that issues, | ||||||
17 | sells, renews, or offers a specialized health insurance policy | ||||||
18 | covering dental services shall meet a minimum dental loss | ||||||
19 | ratio requirement of 80%. | ||||||
20 | (b) If the minimum dental loss ratio is not met, then the | ||||||
21 | Department shall require a corrective action plan from the | ||||||
22 | carrier to return excess premiums.
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23 | Section 20. Rulemaking. The Department may adopt rules to | ||||||
24 | implement this Act.
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1 | Section 25. Exemptions. This Act does not apply to an | ||||||
2 | insurance policy issued, sold, renewed, or offered for health | ||||||
3 | care services or coverage provided as a function of the State | ||||||
4 | of Illinois Medicaid coverage for children or adults or | ||||||
5 | disability insurance for covered benefits in the single | ||||||
6 | specialized area of dental-only health care that pays benefits | ||||||
7 | on a fixed benefit, cash payment-only basis.
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8 | Section 90. The Illinois Insurance Code is amended by | ||||||
9 | adding Section 355.5 as follows:
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10 | (215 ILCS 5/355.5 new) | ||||||
11 | Sec. 355.5. Dental coverage reimbursement; prohibitions. | ||||||
12 | No insurer, dental service plan corporation, professional | ||||||
13 | service corporation, insurance network leasing company, or any | ||||||
14 | company that amends, delivers, issues, or renews an individual | ||||||
15 | or group policy of accident and health insurance on or after | ||||||
16 | the effective date of this amendatory Act of the 103rd General | ||||||
17 | Assembly shall require a dental care provider to incur a fee to | ||||||
18 | access and obtain payment or reimbursement for services | ||||||
19 | provided. A dental plan carrier shall provide a dental care | ||||||
20 | provider with 100% of the contracted amount of the payment or | ||||||
21 | reimbursement. Fees incurred directly by a dental care | ||||||
22 | provider from third parties related to transmitting an | ||||||
23 | automated clearinghouse network claim, transaction management, |
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1 | data management, or portal services and other fees charged by | ||||||
2 | third parties that are not in the control of the dental plan | ||||||
3 | carrier shall not be prohibited by this Section.
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4 | Section 95. The Dental Service Plan Act is amended by | ||||||
5 | changing Sections 25 and 34 as follows:
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6 | (215 ILCS 110/25) (from Ch. 32, par. 690.25)
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7 | Sec. 25. Application of Insurance Code provisions. Dental | ||||||
8 | service
plan corporations and all persons interested therein | ||||||
9 | or dealing therewith
shall be subject to the provisions of | ||||||
10 | Articles IIA, VIII 1/2, XI, and XII 1/2
and
Sections 3.1,
133, | ||||||
11 | 136, 139, 140, 143, 143c, 149, 355.2, 355.3, 367.2, 401, | ||||||
12 | 401.1, 402, 403, 403A, 408,
408.2, and 412, and subsection | ||||||
13 | (15) of Section 367 of the Illinois Insurance
Code.
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14 | (Source: P.A. 99-151, eff. 7-28-15.)
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15 | (215 ILCS 110/34) (from Ch. 32, par. 690.34)
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16 | Sec. 34.
No such corporation shall disburse during any one | ||||||
17 | year , except
upon the approval of the Director, a sum greater | ||||||
18 | than 20% of payments
received from subscribers during that | ||||||
19 | year, as administrative expenses.
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20 | The term "administrative expense" as used in this Section | ||||||
21 | section includes all
expenditures for nonprofessional services | ||||||
22 | and in general all expenses not
directly connected with the | ||||||
23 | payment for dental services, but does not
include expenses of |
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1 | soliciting subscriptions.
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2 | (Source: Laws 1965, p. 2179.)
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3 | Section 99. Effective date. This Act takes effect January | ||||||
4 | 1, 2024.".
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