Ill. Admin. Code tit. 50 § 4525.70

Current through Register Vol. 48, No. 49, December 6, 2024

Section 4525.70 - Filing and Approval of Point of Service Plan Requirements

Every managed care dental plan that is required to offer a point of service plan pursuant to the Act, except those plans that are licensed pursuant to Section 1001 of the Limited Health Service Organization Act [ 215 ILCS 130/1001] , shall be required to file a description of its point of service plan for approval to the Life, Accident and Health Compliance Unit of the Department in accordance with the filing requirements of 50 Ill. Adm. Code 916.

a) The filing shall be comprised of:

1) A managed care dental plan filing and an indemnity filing. Such filing shall be coordinated by the managed care dental plan. The filing must contain reasonable financial incentives for the point of service member to utilize dental services provided or arranged by the designated managed care dental plan primary care provider and shall include:

A) Copies of all policy forms necessary to implement the point of service plan, including the member handbook used to integrate the services provided by the managed care dental plan and the benefits provided by the indemnity carrier; and

B) Enrollment application and member identification card disclosing the name of both the managed care dental plan and the indemnity carrier; and

C) Solicitation material; and

D) Copies of all administrative service contracts between the managed care dental plan and indemnity carrier detailing their respective responsibilities and obligations in offering a point of service plan; and

E) The managed care dental plan shall include in its rate filing the rate level justification and a demonstration of how the out-of-network indemnity benefits to be provided by the indemnity carrier will impact on the managed care dental plan's rates and underlying utilization assumptions. Such documentation shall be deemed confidential by the Department unless specific authorization for disclosure is given by the managed care dental plan; and

F) Written descriptions and illustrative flow charts of how the premium is received and distributed in a timely fashion and how claims will be handled for payment; and

G) A comparison of benefits offered by the managed care dental plan and the indemnity carrier.

2) Out-of-network claims shall be filed with the managed care dental plan. The managed care dental plan is responsible for coordinating payment of all claims.

3) Covered services rendered by a participating provider without proper authorization shall be covered at the out-of-network benefit level.

4) For purposes of coordination of benefits, the two policies comprising the point of service plan shall be considered one policy.

5) For purposes of conversion and State continuation, when by statute the managed care dental plan must provide these provisions, they shall provide each enrollee who has a point of service plan the right to convert to either a managed care dental plan option or indemnity option. The managed care dental plan may, but is not required to, offer the enrollee the right to continue under a point of service plan option. Once the enrollee has chosen an option, the other plan's options will no longer be available. Should the enrollee choose to continue or convert coverage under a point of service plan, the plan shall meet applicable standards for Illinois conversion or continuation requirements. In the event of any inconsistency between these standards, then the most favorable to the enrollee shall apply.

b) Subsequent filings of the point of service plan procedure will only be required, pursuant to Section 5425.80 of this Part, if material modifications occur and are to be submitted to the Life, Accident and Health Compliance Unit of the Department in accordance with the filing requirements of 50 Ill. Adm. Code 916.

c) A managed care dental plan licensed pursuant to Section 1001 of the Limited Health Service Organization Act [ 215 ILCS 130/1001] shall be subject to the point of service requirements contained in Section 3009 of the Limited Health Service Organization Act [ 215 ILCS 130/3009] .

Ill. Admin. Code tit. 50, § 4525.70

Recodified from 5425.70 at 41 Ill. Reg. 4988.