Sec. 25. Provision of information.

578 words·~3 min read·/il/chapter-215/act-109/25

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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:

(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 financial arrangements between providers and the plan.

(2)The service area.

(3)Covered benefits, exclusions, or limitations.

(4)Pre-certification requirements including any requirements for referrals made by

primary care dentists to specialists, and other preauthorization requirements.

(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 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 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 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.

(6)Emergency coverage and benefits.

(7)Out-of-area coverages and benefits, if any.

(8)The process about how participating dentists are selected.

(9)The grievance process, including the telephone number to call to receive information

concerning grievance procedures.

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.

(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.

(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.

(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:

(1)the plan application form includes a space in which each enrollee selects a primary

care provider (dentist);

(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

(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.

(e)Nothing in this Act shall be deemed to require a plan to assign an enrollee to a primary care provider (dentist).