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Illinois Statutes Chapter 215. Insurance § 109/10. Definitions

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§ 10. Definitions. As used in this Act:

Dental care services” means services permitted to be performed by a licensed dentist or any person working under the dentist's supervision as permitted by law.

Dentist” means a person licensed to practice dentistry in any state.

Department” means the Department of Insurance.

Director” means the Director of Insurance.

Emergency dental services” means the provision of dental care for a sudden, acute dental condition that would lead a prudent layperson, who possesses an average knowledge of dentistry, to reasonably expect the absence of immediate care to result in serious impairment to the dentition or would place the person's oral health in serious jeopardy.

Enrollee” means an individual and his or her dependents who are enrolled in a managed care dental plan.

Managed care dental plan” or “plan” means a plan that establishes, operates, or maintains a network of dentists that have entered into agreements with the plan to provide dental care services to enrollees to whom the plan has the obligation to arrange for the provision of or payment for services through organizational arrangements for ongoing quality assurance, utilization review programs, or dispute resolution.

For the purpose of this Act, “managed care dental plans” do not include employee or employer self-insured dental benefit plans under the federal ERISA Act of 1974.  1

Point-of-service plan” means a plan or plans that includes both in-plan covered services and out-of-plan covered services as well as managed dental care plan arrangements in which the risk for out-of-plan covered services is borne through reinsurance. The term also includes indemnity benefits that are underwritten in whole by a licensed insurance carrier or a self-funded employer group. For purposes of this Section, “out-of-plan services” means those services which are obtained from providers who do not have a contract, or any other arrangements, with a managed care dental plan or services obtained without a referral from providers who have contracted to provide services to the enrollees on behalf of the managed care dental plan.

Primary care provider (dentist)” means a dentist, having an arrangement with a managed care dental plan, selected by an enrollee or assigned to an enrollee by a plan to provide dental care services under a managed care dental plan.

Prospective enrollee” means an individual eligible for enrollment in a managed care dental plan offered by that individual's employer.

Provider” means either a general dentist or a dentist who is a licensed specialist.

1 29 U.S.C.A. § 1001 et seq.

Cite this article: - Illinois Statutes Chapter 215. Insurance § 109/10. Definitions - last updated January 01, 2019 |

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