Plain English Breakdown
The source text mentions exceptions ('except as specified') regarding reimbursement amounts but does not detail those specific exceptions.
AB-1629: Rules for Paying Dentists Who Are Not in the Insurance Network
This law requires health plans to pay non-network dentists directly if a patient signs a form, limits how much those dentists can charge patients before insurance pays, and adds new rules about what information must be shared.
What This Bill Does
- Requires health care service plans or insurers that cover dental services to pay noncontracting (out-of-network) providers directly for covered services if the provider submits a written assignment of benefits form signed by the patient.
- Prohibits noncontracting dentists from charging patients more than an estimated cost share amount or a deposit approximating that cost before the insurance plan makes its payment.
- Requires plans to provide predetermination or prior authorization amounts to providers and reimburse them for at least that amount, except as specified.
- Mandates that noncontracting dentists give specific written disclosures to patients before accepting an assignment of benefits.
- Requires plans and insurers to certify under penalty of perjury that information they submit about network adequacy is true and correct.
- Expands the definition of unprofessional conduct for licensed dental providers to include failing to provide required disclosures when not under contract with a plan.
Who It Names or Affects
- Health care service plans and health insurers covering dental services
- Dental providers who do not have a contract with an insurance plan (noncontracting)
- Patients enrolled in or insured by these dental benefit plans
Terms To Know
- Noncontracting provider
- A dentist who does not have a formal agreement to accept set payment rates from an insurance plan.
- Assignment of benefits
- A signed form where the patient agrees that the insurance company should pay the doctor directly instead of paying the patient first.
- Cost sharing
- The portion of medical costs, such as copayments or deductibles, that the patient must pay out of pocket.
Limits and Unknowns
- The official text does not specify an effective date for this bill.
- While the law states no state reimbursement is required for local agencies, it only notes a 'specified reason' without detailing what that reason is in the provided summary.