Illinois 2023-2024 Regular Session

Illinois House Bill HB4789 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	Public Act 103-0832
2	1		HB4789 EnrolledLRB103 36280 RPS 66377 b HB4789 Enrolled LRB103 36280 RPS 66377 b
3	2		HB4789 Enrolled LRB103 36280 RPS 66377 b
4		-	AN ACT concerning regulation.
5		-	Be it enacted by the People of the State of Illinois,
6		-	represented in the General Assembly:
7		-	Section 5. The Illinois Insurance Code is amended by
8		-	changing Section 355.4 and by adding Section 355d as follows:
9		-	(215 ILCS 5/355.4)
10		-	Sec. 355.4. Provider notification of network plan changes.
11		-	(a) As used in this Section:
12		-	"Contracting entity" means any person or company that
13		-	enters into direct contracts with providers for the delivery
14		-	of dental services in the ordinary course of business,
15		-	including a third-party administrator and a dental carrier.
16		-	"Dental carrier" means a dental insurance company, dental
17		-	service corporation, dental plan organization authorized to
18		-	provide dental benefits, or a health insurance plan that
19		-	includes coverage for dental services.
20		-	(b) No dental carrier may automatically enroll a provider
21		-	in a leased network without allowing any provider that is part
22		-	of the dental carrier's provider network to choose to not
23		-	participate by opting out.
24		-	(c) Any contract entered into or renewed on or after the
25		-	effective date of this amendatory Act of the 103rd General
26		-	Assembly that allows the rights and obligations of the
	3	+	1 AN ACT concerning regulation.
	4	+	2 Be it enacted by the People of the State of Illinois,
	5	+	3 represented in the General Assembly:
	6	+	4 Section 5. The Illinois Insurance Code is amended by
	7	+	5 changing Section 355.4 and by adding Section 355d as follows:
	8	+	6 (215 ILCS 5/355.4)
	9	+	7 Sec. 355.4. Provider notification of network plan changes.
	10	+	8 (a) As used in this Section:
	11	+	9 "Contracting entity" means any person or company that
	12	+	10 enters into direct contracts with providers for the delivery
	13	+	11 of dental services in the ordinary course of business,
	14	+	12 including a third-party administrator and a dental carrier.
	15	+	13 "Dental carrier" means a dental insurance company, dental
	16	+	14 service corporation, dental plan organization authorized to
	17	+	15 provide dental benefits, or a health insurance plan that
	18	+	16 includes coverage for dental services.
	19	+	17 (b) No dental carrier may automatically enroll a provider
	20	+	18 in a leased network without allowing any provider that is part
	21	+	19 of the dental carrier's provider network to choose to not
	22	+	20 participate by opting out.
	23	+	21 (c) Any contract entered into or renewed on or after the
	24	+	22 effective date of this amendatory Act of the 103rd General
	25	+	23 Assembly that allows the rights and obligations of the
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33		-	contract to be assigned or leased to another insurer shall
34		-	provide for notice that informs each provider in writing via
35		-	certified mail 60 days before any scheduled assignment or
36		-	lease of the network to which the provider is a contracted
37		-	provider. To be in compliance with this Section, the
38		-	notification must provide the specific URL address where the
39		-	following are located: include all contract terms, a policy
40		-	manual, a fee schedule, and a statement that the provider has
41		-	the right to choose not to participate in third-party access.
42		-	The notification must also provide instructions for how the
43		-	provider may obtain a copy of those materials.
44		-	(d) A dental carrier that leases or assigns its network
45		-	shall not cancel a network participating dentist's contractual
46		-	relationship or otherwise penalize a network participating
47		-	dentist in any way based on whether or not the dentist accepts
48		-	the terms of the assignment or lease. Before accepting the
49		-	terms of an assignment or lease agreement as described in this
50		-	Section, any provider who receives notification of an
51		-	impending assignment or lease must be given the option to
52		-	contract directly with the entities proposing to gain access
53		-	to the provider's network.
54		-	(e) The provisions of this Section do not apply:
55		-	(1) if access to a provider network contract is
56		-	granted to a dental carrier or an entity operating in
57		-	accordance with the same brand licensee program as the
58		-	contracting entity; or
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	34	+	1 contract to be assigned or leased to another insurer shall
	35	+	2 provide for notice that informs each provider in writing via
	36	+	3 certified mail 60 days before any scheduled assignment or
	37	+	4 lease of the network to which the provider is a contracted
	38	+	5 provider. To be in compliance with this Section, the
	39	+	6 notification must provide the specific URL address where the
	40	+	7 following are located: include all contract terms, a policy
	41	+	8 manual, a fee schedule, and a statement that the provider has
	42	+	9 the right to choose not to participate in third-party access.
	43	+	10 The notification must also provide instructions for how the
	44	+	11 provider may obtain a copy of those materials.
	45	+	12 (d) A dental carrier that leases or assigns its network
	46	+	13 shall not cancel a network participating dentist's contractual
	47	+	14 relationship or otherwise penalize a network participating
	48	+	15 dentist in any way based on whether or not the dentist accepts
	49	+	16 the terms of the assignment or lease. Before accepting the
	50	+	17 terms of an assignment or lease agreement as described in this
	51	+	18 Section, any provider who receives notification of an
	52	+	19 impending assignment or lease must be given the option to
	53	+	20 contract directly with the entities proposing to gain access
	54	+	21 to the provider's network.
	55	+	22 (e) The provisions of this Section do not apply:
	56	+	23 (1) if access to a provider network contract is
	57	+	24 granted to a dental carrier or an entity operating in
	58	+	25 accordance with the same brand licensee program as the
	59	+	26 contracting entity; or
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61		-	(2) to a provider network contract for dental services
62		-	provided to beneficiaries of the State employee group
63		-	health insurance program or the medical assistance program
64		-	under the Illinois Public Aid Code.
65		-	(Source: P.A. 103-24, eff. 1-1-24.)
66		-	(215 ILCS 5/355d new)
67		-	Sec. 355d. Denials of claims submitted after prior
68		-	authorization.
69		-	(a) In this Section:
70		-	"Dental carrier" means an insurer, dental service
71		-	corporation, insurance network leasing company, or any company
72		-	that offers individual or group policies of accident and
73		-	health insurance that provide coverage for dental services.
74		-	"Prior authorization" means any written communication that
75		-	is verifiable, whether through issuance or letter, facsimile,
76		-	email, or similar means, indicating that a specific procedure
77		-	is, or multiple procedures are, covered under the patient's
78		-	dental plan and reimbursable at a specific amount, subject to
79		-	applicable coinsurance and deductibles, and issued in response
80		-	to a request submitted by a dentist using a format prescribed
81		-	by the dental carrier.
82		-	(b) Beginning on the effective date of this amendatory Act
83		-	of the 103rd General Assembly, a dental carrier shall not deny
84		-	any claim subsequently submitted for procedures specifically
85		-	included in a prior authorization unless at least one of the
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87	63
88		-	following circumstances applies for each procedure denied:
89		-	(1) benefit limitations, such as annual maximums and
90		-	frequency limitations, that were not applicable at the
91		-	time of the prior authorization are reached due to
92		-	utilization after issuance of the prior authorization;
93		-	(2) the documentation for the claim provided by the
94		-	person submitting the claim clearly fails to support the
95		-	claim as originally authorized;
96		-	(3) if, after the issuance of the prior authorization,
97		-	new procedures are provided to the patient or a change in
98		-	the condition of the patient occurs such that the prior
99		-	authorized procedure would no longer be considered
100		-	medically necessary based on the prevailing standard of
101		-	care;
102		-	(4) if, after the issuance of the prior authorization,
103		-	new procedures are provided to the patient or a change in
104		-	the condition of the patient occurs such that the prior
105		-	authorized procedure would, at that time, require
106		-	disapproval pursuant to the terms and conditions for
107		-	coverage under the plan for the patient in effect at the
108		-	time the prior authorization was used; or
109		-	(5) the claim was denied by a dental carrier due to one
110		-	of the following reasons:
111		-	(A) another payor is responsible for the payment;
112		-	(B) the dentist has already been paid for the
113		-	procedures identified on the claim;
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116		-	(C) the claim was submitted fraudulently or the
117		-	prior authorization was based in whole or material
118		-	part on erroneous information provided to the dental
119		-	carrier; or
120		-	(D) the person receiving the procedure was not
121		-	eligible for the procedure on the date of service and
122		-	the dental carrier did not know, and with the exercise
123		-	of reasonable care could not have known, that person's
124		-	eligibility status.
125		-	A dental carrier shall not recoup a claim solely due to a
126		-	loss of coverage of a patient or ineligibility if, at the time
127		-	of treatment, the dental carrier erroneously confirmed
128		-	coverage and eligibility, but had sufficient information
129		-	available to the dental carrier indicating that the patient
130		-	was no longer covered or was ineligible for coverage.
131		-	(c) The provisions of this Section may not be waived by
132		-	contract. Any contractual agreement entered into or amended,
133		-	delivered, issued, or renewed on or after the effective date
134		-	of this amendatory Act of the 103rd General Assembly that is in
135		-	conflict with this Section or that purports to waive any
136		-	requirement of this Section is null and void.
137		-	Section 10. The Limited Health Service Organization Act is
138		-	amended by changing Section 4003 as follows:
139		-	(215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
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	69	+	HB4789 Enrolled - 3 - LRB103 36280 RPS 66377 b
	70	+	1 (2) to a provider network contract for dental services
	71	+	2 provided to beneficiaries of the State employee group
	72	+	3 health insurance program or the medical assistance program
	73	+	4 under the Illinois Public Aid Code.
	74	+	5 (Source: P.A. 103-24, eff. 1-1-24.)
	75	+	6 (215 ILCS 5/355d new)
	76	+	7 Sec. 355d. Denials of claims submitted after prior
	77	+	8 authorization.
	78	+	9 (a) In this Section:
	79	+	10 "Dental carrier" means an insurer, dental service
	80	+	11 corporation, insurance network leasing company, or any company
	81	+	12 that offers individual or group policies of accident and
	82	+	13 health insurance that provide coverage for dental services.
	83	+	14 "Prior authorization" means any written communication that
	84	+	15 is verifiable, whether through issuance or letter, facsimile,
	85	+	16 email, or similar means, indicating that a specific procedure
	86	+	17 is, or multiple procedures are, covered under the patient's
	87	+	18 dental plan and reimbursable at a specific amount, subject to
	88	+	19 applicable coinsurance and deductibles, and issued in response
	89	+	20 to a request submitted by a dentist using a format prescribed
	90	+	21 by the dental carrier.
	91	+	22 (b) Beginning on the effective date of this amendatory Act
	92	+	23 of the 103rd General Assembly, a dental carrier shall not deny
	93	+	24 any claim subsequently submitted for procedures specifically
	94	+	25 included in a prior authorization unless at least one of the
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142		-	Sec. 4003. Illinois Insurance Code provisions. Limited
143		-	health service organizations shall be subject to the
144		-	provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
145		-	141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
146		-	154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2,
147		-	355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10,
148		-	356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
149		-	356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
150		-	356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
151		-	364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
152		-	444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
153		-	XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
154		-	Nothing in this Section shall require a limited health care
155		-	plan to cover any service that is not a limited health service.
156		-	For purposes of the Illinois Insurance Code, except for
157		-	Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
158		-	health service organizations in the following categories are
159		-	deemed to be domestic companies:
160		-	(1) a corporation under the laws of this State; or
161		-	(2) a corporation organized under the laws of another
162		-	state, 30% or more of the enrollees of which are residents
163		-	of this State, except a corporation subject to
164		-	substantially the same requirements in its state of
165		-	organization as is a domestic company under Article VIII
166		-	1/2 of the Illinois Insurance Code.
167		-	(Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
168	97
169	98
170		-	102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
171		-	1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
172		-	eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
173		-	102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
174		-	1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
175		-	eff. 1-1-24; revised 8-29-23.)
176		-	Section 15. The Voluntary Health Services Plans Act is
177		-	amended by changing Section 10 as follows:
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	105	+	1 following circumstances applies for each procedure denied:
	106	+	2 (1) benefit limitations, such as annual maximums and
	107	+	3 frequency limitations, that were not applicable at the
	108	+	4 time of the prior authorization are reached due to
	109	+	5 utilization after issuance of the prior authorization;
	110	+	6 (2) the documentation for the claim provided by the
	111	+	7 person submitting the claim clearly fails to support the
	112	+	8 claim as originally authorized;
	113	+	9 (3) if, after the issuance of the prior authorization,
	114	+	10 new procedures are provided to the patient or a change in
	115	+	11 the condition of the patient occurs such that the prior
	116	+	12 authorized procedure would no longer be considered
	117	+	13 medically necessary based on the prevailing standard of
	118	+	14 care;
	119	+	15 (4) if, after the issuance of the prior authorization,
	120	+	16 new procedures are provided to the patient or a change in
	121	+	17 the condition of the patient occurs such that the prior
	122	+	18 authorized procedure would, at that time, require
	123	+	19 disapproval pursuant to the terms and conditions for
	124	+	20 coverage under the plan for the patient in effect at the
	125	+	21 time the prior authorization was used; or
	126	+	22 (5) the claim was denied by a dental carrier due to one
	127	+	23 of the following reasons:
	128	+	24 (A) another payor is responsible for the payment;
	129	+	25 (B) the dentist has already been paid for the
	130	+	26 procedures identified on the claim;
	131	+
	132	+
	133	+
	134	+
	135	+
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	141	+	1 (C) the claim was submitted fraudulently or the
	142	+	2 prior authorization was based in whole or material
	143	+	3 part on erroneous information provided to the dental
	144	+	4 carrier; or
	145	+	5 (D) the person receiving the procedure was not
	146	+	6 eligible for the procedure on the date of service and
	147	+	7 the dental carrier did not know, and with the exercise
	148	+	8 of reasonable care could not have known, that person's
	149	+	9 eligibility status.
	150	+	10 A dental carrier shall not recoup a claim solely due to a
	151	+	11 loss of coverage of a patient or ineligibility if, at the time
	152	+	12 of treatment, the dental carrier erroneously confirmed
	153	+	13 coverage and eligibility, but had sufficient information
	154	+	14 available to the dental carrier indicating that the patient
	155	+	15 was no longer covered or was ineligible for coverage.
	156	+	16 (c) The provisions of this Section may not be waived by
	157	+	17 contract. Any contractual agreement entered into or amended,
	158	+	18 delivered, issued, or renewed on or after the effective date
	159	+	19 of this amendatory Act of the 103rd General Assembly that is in
	160	+	20 conflict with this Section or that purports to waive any
	161	+	21 requirement of this Section is null and void.
	162	+	22 Section 10. The Limited Health Service Organization Act is
	163	+	23 amended by changing Section 4003 as follows:
	164	+	24 (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
	165	+
	166	+
	167	+
	168	+
	169	+
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	171	+
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	174	+	HB4789 Enrolled - 6 - LRB103 36280 RPS 66377 b
	175	+	1 Sec. 4003. Illinois Insurance Code provisions. Limited
	176	+	2 health service organizations shall be subject to the
	177	+	3 provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
	178	+	4 141.2, 141.3, 143, 143c, 147, 148, 149, 151, 152, 153, 154,
	179	+	5 154.5, 154.6, 154.7, 154.8, 155.04, 155.37, 155.49, 355.2,
	180	+	6 355.3, 355b, 355d, 356q, 356v, 356z.4, 356z.4a, 356z.10,
	181	+	7 356z.21, 356z.22, 356z.25, 356z.26, 356z.29, 356z.30a,
	182	+	8 356z.32, 356z.33, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
	183	+	9 356z.54, 356z.57, 356z.59, 356z.61, 356z.64, 356z.67, 356z.68,
	184	+	10 364.3, 368a, 401, 401.1, 402, 403, 403A, 408, 408.2, 409, 412,
	185	+	11 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII 1/2, XIII,
	186	+	12 XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
	187	+	13 Nothing in this Section shall require a limited health care
	188	+	14 plan to cover any service that is not a limited health service.
	189	+	15 For purposes of the Illinois Insurance Code, except for
	190	+	16 Sections 444 and 444.1 and Articles XIII and XIII 1/2, limited
	191	+	17 health service organizations in the following categories are
	192	+	18 deemed to be domestic companies:
	193	+	19 (1) a corporation under the laws of this State; or
	194	+	20 (2) a corporation organized under the laws of another
	195	+	21 state, 30% or more of the enrollees of which are residents
	196	+	22 of this State, except a corporation subject to
	197	+	23 substantially the same requirements in its state of
	198	+	24 organization as is a domestic company under Article VIII
	199	+	25 1/2 of the Illinois Insurance Code.
	200	+	26 (Source: P.A. 102-30, eff. 1-1-22; 102-203, eff. 1-1-22;
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	203	+
	204	+
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	210	+	HB4789 Enrolled - 7 - LRB103 36280 RPS 66377 b
	211	+	1 102-306, eff. 1-1-22; 102-642, eff. 1-1-22; 102-731, eff.
	212	+	2 1-1-23; 102-775, eff. 5-13-22; 102-813, eff. 5-13-22; 102-816,
	213	+	3 eff. 1-1-23; 102-860, eff. 1-1-23; 102-1093, eff. 1-1-23;
	214	+	4 102-1117, eff. 1-13-23; 103-84, eff. 1-1-24; 103-91, eff.
	215	+	5 1-1-24; 103-420, eff. 1-1-24; 103-426, eff. 8-4-23; 103-445,
	216	+	6 eff. 1-1-24; revised 8-29-23.)
	217	+	7 Section 15. The Voluntary Health Services Plans Act is
	218	+	8 amended by changing Section 10 as follows:
	219	+	9 (215 ILCS 165/10) (from Ch. 32, par. 604)
	220	+	10 Sec. 10. Application of Insurance Code provisions. Health
	221	+	11 services plan corporations and all persons interested therein
	222	+	12 or dealing therewith shall be subject to the provisions of
	223	+	13 Articles IIA and XII 1/2 and Sections 3.1, 133, 136, 139, 140,
	224	+	14 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b,
	225	+	15 355d, 356g, 356g.5, 356g.5-1, 356q, 356r, 356t, 356u, 356v,
	226	+	16 356w, 356x, 356y, 356z.1, 356z.2, 356z.3a, 356z.4, 356z.4a,
	227	+	17 356z.5, 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12,
	228	+	18 356z.13, 356z.14, 356z.15, 356z.18, 356z.19, 356z.21, 356z.22,
	229	+	19 356z.25, 356z.26, 356z.29, 356z.30, 356z.30a, 356z.32,
	230	+	20 356z.33, 356z.40, 356z.41, 356z.46, 356z.47, 356z.51, 356z.53,
	231	+	21 356z.54, 356z.56, 356z.57, 356z.59, 356z.60, 356z.61, 356z.62,
	232	+	22 356z.64, 356z.67, 356z.68, 364.01, 364.3, 367.2, 368a, 401,
	233	+	23 401.1, 402, 403, 403A, 408, 408.2, and 412, and paragraphs (7)
	234	+	24 and (15) of Section 367 of the Illinois Insurance Code.
	235	+
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	237	+
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