(215 ILCS 109/25)
Sec. 25. Provision of information.
(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.
(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).
(Source: P.A. 91-355, eff. 1-1-00.)
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Last modified: February 18, 2015