Dental providers: fee-based payments.

Plain English Breakdown

The official source does not specify the exact conditions under which a dental provider can opt out of fee-based payments, but it requires affirmative consent for opting in or out.

Dental Providers: Fee-Based Payments

The law requires health care service plans and insurers to use non-fee-based default payment methods for dental providers, and mandates obtaining the provider's consent before switching them to fee-based payments.

What This Bill Does

• Requires health care service plans and health insurers to have a non-fee-based default method of paying dental providers.
• Needs health care service plans or insurers to get affirmative consent from dental providers before using fee-based payment methods.
• Allows dental providers to opt out of fee-based payments at any time by providing their agreement.
• Applies the decision about payment methods to all services and products covered in the contract between the provider and the plan or insurer.
• Does not apply if there is an existing direct contract that allows the dental provider to choose payment methods.

Who It Names or Affects

• Health care service plans
• Health insurers
• Dental providers

Terms To Know

Fee-based payment method

A way of paying dental providers based on fees set by the health plan or insurer.

Non-fee-based default method

The standard way of paying dental providers that is not fee-based and must be used unless a provider agrees to use a different method.

Limits and Unknowns

• Does not apply if there is an existing direct contract between the health plan or insurer and the dental provider.
• Effective on April 1, 2026, for contracts issued, amended, or renewed after that date.

Official Summary Text

SB 386, Limón.
Dental providers: fee-based payments.
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 imposes specified coverage and disclosure requirements on health care service plans and health insurers, including specialized plans and insurers, that cover dental services.
This bill would require a health care service plan or health insurer that provides payment directly or through a contracted vendor to a dental provider to have a non-fee-based default method of payment, as specified. The bill would require a health care service plan, health insurer, or contracted vendor to obtain affirmative consent from a dental provider who opts in to a fee-based payment method before the plan or vendor provides a fee-based payment method to the provider. The bill would authorize a dental provider to opt out of a fee-based payment method at any time by providing affirmative consent to the health care service plan, health insurer, or contracted vendor. The bill would require a health care service
plan, health insurer, or contracted vendor that obtains affirmative consent to opt in or opt out of fee-based payment to apply the decision to include both the dental provider’s entire practice and all products or services covered pursuant to a contract with the dental provider, as specified. The bill would specify that its provisions do not apply if a health care service plan or health insurer has a direct contract with a provider that allows the provider to choose payment methods, including a non-fee-based payment method for services rendered. The bill would make its provisions operative on April 1, 2026, and apply to health care service plan contracts and health insurance policies issued, amended, or renewed on or after that date.
Because a violation of the bill’s requirements by a health care service plan would be a crime, the bill would impose a
state-mandated local program.
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