Dental insurance -- Contract provision for noncovered services.
Checkout our iOS App for a better way to browser and research.
(1) For purposes of this section:
(a) "Covered services" means dental services for which reimbursement:
(i) is available or would be reimbursable under an enrollee's dental plan but for the application of one or more of the following contractual provisions:
(A) deductibles;
(B) copayments;
(C) coinsurance;
(D) waiting periods;
(E) annual or lifetime maximums;
(F) frequency limitations; or
(G) alternative benefit payments; and
(ii) is not merely nominal, for the purpose of avoiding the requirements of this section.
(b) "Dental plan"means:
(i) a health benefit plan that includes coverage for dental services; and
(ii) a policy or certificate that provides coverage solely for dental services.
(c) "Dentist" means an individual licensed under Title 58, Chapter 69, Dentist and Dental Hygienist Practice Act.
(2)
(a) This section applies to:
(i) a dental plan that is entered into or renewed on or after January 1, 2018; and
(ii) an administrator providing third-party administration services or a provider network for a dental plan.
(b) This section does not apply to a self-insured dental plan that is regulated by federal law.
(3) A contract between a dental plan and a dentist to provide covered services may not:
(a) require, directly or indirectly, that a dentist provide dental services to a covered individual at a fee set by, or a fee subject to the approval of, the dental plan unless:
(i) the dental services are covered services under the dental plan; or
(ii)
(A) the dental services are not reimbursed by the dental plan;
(B) the dental services are discounted for individuals who are part of a discount dental rates plan; and
(C) the dentist who provided the dental services has elected to participate in the discount dental rates plan; and
(b) prohibit a dentist from offering or providing noncovered dental services to a covered individual at a fee determined by the dentist and the individual who will receive the noncovered services.
Technically renumbered to avoid duplication of section number also enacted in HB42, Chapter 168.