Dental coverage.

Plain English Breakdown

The official source material does not provide specific details on the exact nature of disclosures required from noncontracting dental providers.

Dental Coverage Law

AB-1629 requires health plans and insurers to pay noncontracting dental providers directly if the patient gives permission, sets rules for payment amounts, and mandates reviews of dental provider networks.

What This Bill Does

• Requires health care service plans or insurers to pay a dentist who is not part of their network directly if the patient signs a form giving permission.
• Sets minimum payment requirements for noncontracting dentists from health plans and insurers.
• Mandates that health plans notify patients when out-of-network costs are covered by their annual or lifetime maximum limits.
• Requires dental providers to inform patients about certain details before accepting an assignment of benefits.
• Directs the Department of Managed Health Care and the Department of Insurance to review the adequacy of entire dental provider networks.

Who It Names or Affects

• Health care service plans
• Insurance companies
• Dental providers who are not part of a health plan's network
• Patients receiving dental services

Terms To Know

Assignment of benefits form

A document signed by the patient that allows a dentist to receive payment directly from the insurance company.

Noncontracting dental provider

A dentist who is not part of a health plan's network but still provides services to patients covered by that plan.

Limits and Unknowns

• The bill does not specify how the adequacy of dental provider networks will be reviewed.
• It is unclear what specific details noncontracting dental providers must disclose to patients before accepting an assignment of benefits form.

Official Summary Text

AB 1629, as introduced, Haney.
Dental coverage.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act’s requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law prohibits a contract between a plan or insurer and a dentist from requiring a dentist to accept an amount set by the plan or insurer as payment for dental care services provided to an enrollee or insured that are not covered services under the enrollee’s contract or the insured’s policy. Existing law requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services.
Existing law requires a health care service plan or health insurer to comply with
specified timely access requirements. Under existing law, a health care service plan is required to annually report to the Department of Managed Health Care on this compliance. Existing law authorizes the Department of Insurance to issue guidance to insurers regarding annual timely access and network reporting methodologies.
If a health care service plan or health insurer pays a contracting dental provider directly for covered services, this bill would require the plan or insurer to pay a noncontracting dental provider directly for covered services if the noncontracting provider submits to the plan or insurer a written assignment of benefits form signed by the enrollee or insured. The bill would require the plan or insurer to provide a predetermination or prior authorization to the dental provider and to reimburse the provider for not less than that amount, except as specified. The bill would require the plan or insurer to notify the enrollee or insured that the
provider was paid and that the out-of-network cost may count towards their annual or lifetime maximum. The bill would require a noncontracting dental provider to make specified disclosures to an enrollee or insured before accepting an assignment of benefits. Because a willful violation of these provisions relative to health care service plans would be a crime, this bill would impose a state-mandated local program.
This bill would require the Department of Managed Health Care and the Department of Insurance to review the adequacy of an entire dental provider network, including the portions of the network serving plans and insurers not regulated by the respective department.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.

Current Bill Text

Download Bill PDF