103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4780 Introduced , by Rep. Jennifer Gong-Gershowitz SYNOPSIS AS INTRODUCED: New Act Creates the Dental Loss Ratio Act. Sets forth provisions concerning dental loss ratio reporting. Provides that a health insurer or dental plan carrier that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, beginning January 1, 2025, annually submit to the Department of Insurance a dental loss ratio filing. Provides a formula for calculating minimum dental loss ratios. Sets forth provisions concerning minimum dental loss ratio requirements. Provides that the Department may adopt rules to implement the Act. Provides that the Act does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided as a function of the State of Illinois Medicaid coverage for children or adults or disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment-only basis. Defines terms. Effective January 1, 2025. LRB103 36283 AWJ 66380 b A BILL FOR 103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4780 Introduced , by Rep. Jennifer Gong-Gershowitz SYNOPSIS AS INTRODUCED: New Act New Act Creates the Dental Loss Ratio Act. Sets forth provisions concerning dental loss ratio reporting. Provides that a health insurer or dental plan carrier that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, beginning January 1, 2025, annually submit to the Department of Insurance a dental loss ratio filing. Provides a formula for calculating minimum dental loss ratios. Sets forth provisions concerning minimum dental loss ratio requirements. Provides that the Department may adopt rules to implement the Act. Provides that the Act does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided as a function of the State of Illinois Medicaid coverage for children or adults or disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment-only basis. Defines terms. Effective January 1, 2025. LRB103 36283 AWJ 66380 b LRB103 36283 AWJ 66380 b A BILL FOR
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4780 Introduced , by Rep. Jennifer Gong-Gershowitz SYNOPSIS AS INTRODUCED:
New Act New Act
New Act
Creates the Dental Loss Ratio Act. Sets forth provisions concerning dental loss ratio reporting. Provides that a health insurer or dental plan carrier that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, beginning January 1, 2025, annually submit to the Department of Insurance a dental loss ratio filing. Provides a formula for calculating minimum dental loss ratios. Sets forth provisions concerning minimum dental loss ratio requirements. Provides that the Department may adopt rules to implement the Act. Provides that the Act does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided as a function of the State of Illinois Medicaid coverage for children or adults or disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment-only basis. Defines terms. Effective January 1, 2025.
LRB103 36283 AWJ 66380 b LRB103 36283 AWJ 66380 b
LRB103 36283 AWJ 66380 b
A BILL FOR
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HB4780 LRB103 36283 AWJ 66380 b
1 AN ACT concerning regulation.
2 Be it enacted by the People of the State of Illinois,
3 represented in the General Assembly:
4 Section 1. Short title. This Act may be referred to as the
5 Dental Loss Ratio Act.
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,
17 including an accident and health insurance company, a health
18 maintenance organization, a limited health service
19 organization, a dental service plan corporation, a health
20 services plan corporation, a voluntary health services plan,
21 or any other entity providing a plan of dental insurance,
22 dental benefits, or dental health care services.
23 "Department" means the Department of Insurance.
103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4780 Introduced , by Rep. Jennifer Gong-Gershowitz SYNOPSIS AS INTRODUCED:
New Act New Act
New Act
Creates the Dental Loss Ratio Act. Sets forth provisions concerning dental loss ratio reporting. Provides that a health insurer or dental plan carrier that issues, sells, renews, or offers a specialized health insurance policy covering dental services shall, beginning January 1, 2025, annually submit to the Department of Insurance a dental loss ratio filing. Provides a formula for calculating minimum dental loss ratios. Sets forth provisions concerning minimum dental loss ratio requirements. Provides that the Department may adopt rules to implement the Act. Provides that the Act does not apply to an insurance policy issued, sold, renewed, or offered for health care services or coverage provided as a function of the State of Illinois Medicaid coverage for children or adults or disability insurance for covered benefits in the single specialized area of dental-only health care that pays benefits on a fixed benefit, cash payment-only basis. Defines terms. Effective January 1, 2025.
LRB103 36283 AWJ 66380 b LRB103 36283 AWJ 66380 b
LRB103 36283 AWJ 66380 b
A BILL FOR
New Act
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1 "Director" means the Director of Insurance.
2 "Earned premiums" means the portion of the premium paid in
3 the reporting year that is intended to provide coverage during
4 that reporting period.
5 "Incurred claims" means the claims for which services were
6 provided in that reporting year. "Incurred claims" includes
7 claims that were paid in the reporting year plus unpaid claim
8 reserves for claims paid after the reporting year.
9 Section 10. Dental loss ratio reporting.
10 (a) A health insurer or dental plan carrier that issues,
11 sells, renews, or offers a specialized health insurance policy
12 covering dental services shall, beginning January 1, 2025,
13 annually submit to the Department the dental loss ratio
14 calculated in accordance with subsection (c). The annual
15 filing shall, at a minimum, include rates, rating schedules,
16 and supporting documentation, including ratios of incurred
17 claims to earned premiums for each calendar year since the
18 plan's issuance. The required information shall be in the form
19 established by the Department and shall demonstrate that each
20 plan complies with the minimum dental loss ratio standards.
21 (b) The annual filing shall be made publicly available on
22 the Department's website.
23 (c) The dental loss ratio for a dental plan or dental
24 coverage of a health benefit plan shall be determined by
25 dividing the numerator by the denominator as follows:
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1 (1) The numerator is the amount spent on dental care.
2 The amount spent on dental care includes:
3 (A) the amount expended for clinical dental
4 services that are services within the American Dental
5 Association's Code on Dental Procedures and
6 Nomenclature provided to enrollees that includes
7 payments under capitation contracts with dental
8 providers and covered by the contract for dental
9 clinical services or supplies covered by the contract;
10 (B) reserves and liabilities established to
11 account for claims that were incurred during the
12 reporting year but were not paid within 3 months of the
13 end of the reporting year; and
14 (C) any claim payment recovered by insurers from
15 providers or enrollees using utilization management
16 efforts that will be deducted from incurred claims
17 amounts.
18 (2) The calculation of the numerator does not include:
19 (A) overpayments that have already been received
20 from providers that should not be reported as a paid
21 claim; overpayment recoveries received from providers
22 must be deducted from incurred claims amounts;
23 (B) administrative costs, including, but not
24 limited to, infrastructure, personnel costs, or broker
25 payments;
26 (C) amounts paid to third-party vendors for
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1 secondary network savings;
2 (D) amounts paid to third-party vendors for
3 network development, administrative fees, claims
4 processing, and utilization management; or
5 (E) amounts paid to providers for professional or
6 administrative services that do not represent
7 compensation or reimbursement for covered services
8 provided to an enrollee, including, but not limited
9 to, dental record copying costs, attorney's fees,
10 subrogation vendor fees, compensation to
11 paraprofessionals, janitors, quality assurance
12 analysts, administrative supervisors, secretaries to
13 dental personnel, and dental record clerks.
14 (3) The denominator is the total amount of the earned
15 premium revenues, excluding federal and State taxes and
16 licensing and regulatory fees paid after accounting for
17 any payments pursuant to federal law. In this paragraph,
18 "earned premium revenues" means all moneys paid by a
19 policyholder or subscriber as a condition of receiving
20 coverage from the issuer, including any fees or other
21 contributions associated with the dental plan.
22 (d) If the Director decides to conduct an examination
23 because the Director finds it necessary to verify a health
24 insurer's or dental plan carrier's representation in a dental
25 loss ratio report, then the Department shall provide the
26 health insurer or dental plan carrier with a notification 30
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1 days before the commencement of the examination.
2 (e) The health insurer or dental plan carrier shall have
3 30 days after the date of notification to electronically
4 submit to the Department all requested records specified by
5 the Department. The Director may extend the time for a health
6 insurer or dental plan carrier to comply with this examination
7 upon a finding of good cause.
8 Section 15. Dental loss ratio requirement.
9 (a) A health insurer or dental plan carrier that issues,
10 sells, renews, or offers a specialized health insurance policy
11 covering dental services shall meet a minimum dental loss
12 ratio requirement of 80%.
13 (b) If the minimum dental loss ratio is not met, then the
14 Department shall require a corrective action plan from the
15 carrier to return excess premiums.
16 Section 20. Rulemaking. The Department may adopt rules to
17 implement this Act.
18 Section 25. Exemptions. This Act does not apply to an
19 insurance policy issued, sold, renewed, or offered for health
20 care services or coverage provided as a function of the State
21 of Illinois Medicaid coverage for children or adults or
22 disability insurance for covered benefits in the single
23 specialized area of dental-only health care that pays benefits
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1 on a fixed benefit, cash payment-only basis.
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