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SECOND REGULAR SESSION
SENATE BILL NO. 1596
103RD GENERAL ASSEMBLY
INTRODUCED BY SENATOR CARTER.
6717S.01I KRISTINA MARTIN, Secretary
AN ACT
To amend chapter 354, RSMo, by adding thereto one new section relating to dental plans.
Be it enacted by the General Assembly of the State of Missouri, as follows:
Section A. Chapter 354, RSMo, is amended by adding thereto 1
one new section, to be known as section 354.718, to read as 2
follows:3
354.718. 1. As used in this section, the following 1
terms mean: 2
(1) "Dental loss ratio", the percentage of the amount 3
of premiums received by a dental plan expended on actual 4
patient care rather than overhead or administrative costs, 5
as determined by the following fraction: 6
(a) The numerator shall be the amount expended for 7
clinical dental services provided to dental plan enrollees, 8
including payments under capitation contracts with dental 9
providers, during the reporting year together with unpaid 10
claim reserves for dental services performed during the 11
reporting year but not yet paid. The numerator shall not 12
include: 13
a. Administrative costs including, but not limited to, 14
infrastructure costs, personnel costs, or broker payments; 15
b. Amounts paid to third-party vendors for secondary 16
network savings; 17
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c. Amounts paid to third-party vendors for network 18
development, administrative fees, claims processing, and 19
utilization management; 20
d. Amounts paid to providers for professional or 21
administrative services that do not represent compensation 22
or reimbursement for covered services provided to an 23
enrollee including, but not limited to, dental record 24
copying costs, attorney's fees, subrogation vendor fees, and 25
compensation to paraprofessionals, janitors, quality 26
assurance analysts, administrative supervisors, secretaries 27
to dental personnel, and dental record clerks; or 28
e. Overpayments made by the provider that were 29
recovered by the dental plan and not previously reported on 30
any dental loss ratio report; and 31
(b) The denominator shall be all earned premiums 32
received by the dental plan for dental services, excluding 33
federal and state taxes; licensing fees; regulatory fees; 34
payments or receipts for risk adjustment, risk corridors, 35
and reinsurance; community benefit expenditures, as defined 36
in 45 CFR 158.162(c); and any other payments required by 37
federal law; 38
(2) "Dental plan", any health benefit plan, or portion 39
of a health benefit plan, that issues, sells, renews, or 40
offers a contract covering dental care services. The term 41
"dental plan" shall not include any health benefit plan for 42
health care services under MO HealthNet, the state 43
children's health insurance program authorized in sections 44
208.631 to 208.658, or any other state-sponsored health 45
insurance program. 46
2. (1) A dental plan shall file with the department 47
of commerce and insurance a dental loss ratio report for 48
each calendar year during which the dental plan provided 49
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dental coverage containing the same information as required 50
in the 2013 federal dental loss ratio annual reporting form 51
(CMS-10418). All terms used in the dental loss ratio annual 52
report shall have the same meanings as used in the federal 53
Public Health Service Act, 42 U.S.C. Section 300gg-18, and 54
45 CFR Part 158. 55
(2) The dental loss ratio report shall be filed before 56
March first of each year for the previous calendar year. If 57
the department of commerce and insurance requires data 58
verification of the dental loss ratio report, it shall give 59
the dental plan thirty days' notice of the additional 60
information and data required to be submitted to the 61
department. The dental plan shall submit the information 62
requested within thirty days of such notice. The department 63
shall be deemed to have approved all dental loss ratio 64
reports within ninety days of the filing of the reports 65
unless a dental plan is notified otherwise. 66
(3) The department of commerce and insurance shall 67
make available to the public all the data provided to the 68
department in accordance with this section. 69
3. A dental plan shall provide an annual rebate to 70
each enrollee, on a pro rata basis, to the extent the dental 71
loss ratio is less than eighty-five percent before August 72
first of the year following the year for which the dental 73
loss ratio report was issued. The total annual rebate is 74
the excess revenue expended by the dental plan on overhead 75
or administrative costs, as determined by the amount by 76
which the denominator of the dental loss ratio exceeds the 77
numerator. 78
4. Any failure to rebate the amount prescribed in 79
subsection 3 of this section by a dental plan not required 80
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to be licensed by the department of commerce and insurance 81
shall be deemed an unlawful practice under section 407.020. 82
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