Illinois 2023-2024 Regular Session

Illinois House Bill HB4780 Compare Versions

Only one version of the bill is available at this time.

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1	1	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
2	2	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4780 Introduced , by Rep. Jennifer Gong-Gershowitz SYNOPSIS AS INTRODUCED:
3	3	New Act New Act
4	4	New Act
5	5	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.
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8	8	A BILL FOR
9	9	HB4780LRB103 36283 AWJ 66380 b HB4780 LRB103 36283 AWJ 66380 b
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11	11	1 AN ACT concerning regulation.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 1. Short title. This Act may be referred to as the
15	15	5 Dental Loss Ratio Act.
16	16	6 Section 5. Definitions. As used in this Act:
17	17	7 "Dental care provider" means a dentist who bills for
18	18	8 services in Illinois.
19	19	9 "Dental loss ratio" means the ratio of incurred claims to
20	20	10 earned premiums as calculated using the formula under Section
21	21	11 10 of this Act.
22	22	12 "Dental plan carrier" means an entity subject to the
23	23	13 insurance laws, rules, and regulations of this State or
24	24	14 subject to the jurisdiction of the Director that contracts or
25	25	15 offers to contract to provide, deliver, arrange for, pay for,
26	26	16 or reimburse any of the costs of dental care services,
27	27	17 including an accident and health insurance company, a health
28	28	18 maintenance organization, a limited health service
29	29	19 organization, a dental service plan corporation, a health
30	30	20 services plan corporation, a voluntary health services plan,
31	31	21 or any other entity providing a plan of dental insurance,
32	32	22 dental benefits, or dental health care services.
33	33	23 "Department" means the Department of Insurance.
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37	37	103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4780 Introduced , by Rep. Jennifer Gong-Gershowitz SYNOPSIS AS INTRODUCED:
38	38	New Act New Act
39	39	New Act
40	40	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.
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68	68	1 "Director" means the Director of Insurance.
69	69	2 "Earned premiums" means the portion of the premium paid in
70	70	3 the reporting year that is intended to provide coverage during
71	71	4 that reporting period.
72	72	5 "Incurred claims" means the claims for which services were
73	73	6 provided in that reporting year. "Incurred claims" includes
74	74	7 claims that were paid in the reporting year plus unpaid claim
75	75	8 reserves for claims paid after the reporting year.
76	76	9 Section 10. Dental loss ratio reporting.
77	77	10 (a) A health insurer or dental plan carrier that issues,
78	78	11 sells, renews, or offers a specialized health insurance policy
79	79	12 covering dental services shall, beginning January 1, 2025,
80	80	13 annually submit to the Department the dental loss ratio
81	81	14 calculated in accordance with subsection (c). The annual
82	82	15 filing shall, at a minimum, include rates, rating schedules,
83	83	16 and supporting documentation, including ratios of incurred
84	84	17 claims to earned premiums for each calendar year since the
85	85	18 plan's issuance. The required information shall be in the form
86	86	19 established by the Department and shall demonstrate that each
87	87	20 plan complies with the minimum dental loss ratio standards.
88	88	21 (b) The annual filing shall be made publicly available on
89	89	22 the Department's website.
90	90	23 (c) The dental loss ratio for a dental plan or dental
91	91	24 coverage of a health benefit plan shall be determined by
92	92	25 dividing the numerator by the denominator as follows:
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103	103	1 (1) The numerator is the amount spent on dental care.
104	104	2 The amount spent on dental care includes:
105	105	3 (A) the amount expended for clinical dental
106	106	4 services that are services within the American Dental
107	107	5 Association's Code on Dental Procedures and
108	108	6 Nomenclature provided to enrollees that includes
109	109	7 payments under capitation contracts with dental
110	110	8 providers and covered by the contract for dental
111	111	9 clinical services or supplies covered by the contract;
112	112	10 (B) reserves and liabilities established to
113	113	11 account for claims that were incurred during the
114	114	12 reporting year but were not paid within 3 months of the
115	115	13 end of the reporting year; and
116	116	14 (C) any claim payment recovered by insurers from
117	117	15 providers or enrollees using utilization management
118	118	16 efforts that will be deducted from incurred claims
119	119	17 amounts.
120	120	18 (2) The calculation of the numerator does not include:
121	121	19 (A) overpayments that have already been received
122	122	20 from providers that should not be reported as a paid
123	123	21 claim; overpayment recoveries received from providers
124	124	22 must be deducted from incurred claims amounts;
125	125	23 (B) administrative costs, including, but not
126	126	24 limited to, infrastructure, personnel costs, or broker
127	127	25 payments;
128	128	26 (C) amounts paid to third-party vendors for
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139	139	1 secondary network savings;
140	140	2 (D) amounts paid to third-party vendors for
141	141	3 network development, administrative fees, claims
142	142	4 processing, and utilization management; or
143	143	5 (E) amounts paid to providers for professional or
144	144	6 administrative services that do not represent
145	145	7 compensation or reimbursement for covered services
146	146	8 provided to an enrollee, including, but not limited
147	147	9 to, dental record copying costs, attorney's fees,
148	148	10 subrogation vendor fees, compensation to
149	149	11 paraprofessionals, janitors, quality assurance
150	150	12 analysts, administrative supervisors, secretaries to
151	151	13 dental personnel, and dental record clerks.
152	152	14 (3) The denominator is the total amount of the earned
153	153	15 premium revenues, excluding federal and State taxes and
154	154	16 licensing and regulatory fees paid after accounting for
155	155	17 any payments pursuant to federal law. In this paragraph,
156	156	18 "earned premium revenues" means all moneys paid by a
157	157	19 policyholder or subscriber as a condition of receiving
158	158	20 coverage from the issuer, including any fees or other
159	159	21 contributions associated with the dental plan.
160	160	22 (d) If the Director decides to conduct an examination
161	161	23 because the Director finds it necessary to verify a health
162	162	24 insurer's or dental plan carrier's representation in a dental
163	163	25 loss ratio report, then the Department shall provide the
164	164	26 health insurer or dental plan carrier with a notification 30
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175	175	1 days before the commencement of the examination.
176	176	2 (e) The health insurer or dental plan carrier shall have
177	177	3 30 days after the date of notification to electronically
178	178	4 submit to the Department all requested records specified by
179	179	5 the Department. The Director may extend the time for a health
180	180	6 insurer or dental plan carrier to comply with this examination
181	181	7 upon a finding of good cause.
182	182	8 Section 15. Dental loss ratio requirement.
183	183	9 (a) A health insurer or dental plan carrier that issues,
184	184	10 sells, renews, or offers a specialized health insurance policy
185	185	11 covering dental services shall meet a minimum dental loss
186	186	12 ratio requirement of 80%.
187	187	13 (b) If the minimum dental loss ratio is not met, then the
188	188	14 Department shall require a corrective action plan from the
189	189	15 carrier to return excess premiums.
190	190	16 Section 20. Rulemaking. The Department may adopt rules to
191	191	17 implement this Act.
192	192	18 Section 25. Exemptions. This Act does not apply to an
193	193	19 insurance policy issued, sold, renewed, or offered for health
194	194	20 care services or coverage provided as a function of the State
195	195	21 of Illinois Medicaid coverage for children or adults or
196	196	22 disability insurance for covered benefits in the single
197	197	23 specialized area of dental-only health care that pays benefits
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