Dental insurance practices

AN ACT Relating to ensuring patient choice and access to care by 1
prohibiting unfair and deceptive dental insurance practices; amending 2
RCW 48.44.035, 48.44.495, and 48.43.743; adding new sections to 3
chapter 48.44 RCW; adding new sections to chapter 48.43 RCW; and 4
creating new sections. 5
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:6
NEW SECTION. Sec. 1. The legislature finds that the dental 7
benefits system in Washington is failing both patients and dental 8
professionals, as it primarily benefits corporate insurance companies 9
rather than those it is meant to serve. Insurance executives, whose 10
bonuses increase when payouts to patients decrease, dominate the 11
system, leaving patients and providers struggling to navigate a 12
system that prioritizes profits over care.13
Therefore, the legislature seeks to reform this broken system by 14
putting patients at the center, ensuring the system works for all 15
stakeholders, especially those in need. The goal of this act is to 16
bring equity, transparency, and fairness to the dental insurance 17
market. By aligning dental insurance protections with those already 18
established for medical insurance, it ensures patients have the same 19
rights and protections. The focus is on making dental benefits work 20
for people, not corporations. A key element of the reform is 21
S-0509.1
SENATE BILL 5351
State of Washington 69th Legislature 2025 Regular Session
By Senators King, Chapman, Cleveland, Muzzall, Orwall, Christian,
Nobles, Harris, Salomon, Conway, Frame, Hasegawa, Holy, Shewmake, and
Trudeau
Read first time 01/17/25. Referred to Committee on Health & Long-
Term Care.
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protecting patient choice. Patients should be able to choose a 1
trusted dentist and receive the full benefits they pay for, 2
regardless of network restrictions. Therefore, the legislature 3
intends to eliminate corporate restrictions that limit care and 4
undermine the patient-provider relationship. 5
Additionally, the legislature intends to mandate that at least 85 6
percent of premium dollars be spent directly on care, ensuring that 7
patients get value for what they pay. The legislature further intends 8
for patients to request an independent review of denied claims, 9
empowering them to receive necessary care, as well as tackling 10
additional actions by insurance companies taking advantage of 11
patients and providers. This act addresses inequities in the dental 12
benefits system, especially for vulnerable populations, by creating a 13
fairer, more transparent market that improves access to care and 14
reduces out-of-pocket costs for all Washington residents.15
NEW SECTION. Sec. 2. A new section is added to chapter 48.44 16
RCW to read as follows: 17
(1)(a) A limited health care service contractor that offers 18
coverage for dental care services shall permit a treating dentist, in 19
consultation with the covered person, to make all decisions on dental 20
services provided to the covered person, rather than making such 21
decisions through contracts or agreements between the dentist and the 22
limited health care service contractor. 23
(b) Consistent with (a) of this subsection, the limited health 24
care service contractor may not: 25
(i) Deny coverage for services provided by the dentist based on 26
an independent diagnosis made by the limited health care service 27
contractor or an employee or agent of the limited health care service 28
contractor; or 29
(ii) Deny coverage for procedures on the basis that the 30
procedures were performed on the same day. 31
(c) The decisions made by the dentist, in consultation with the 32
covered person, under (a) of this subsection must be based on 33
accepted dental practices. 34
(2) A limited health care service contractor that offers coverage 35
for dental care services may not modify the reimbursement rates paid 36
to a contracting dentist during the term of the contract, unless the 37
contracting dentist agrees to the modification in writing.38
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(3) For purposes of this section, "limited health care service 1
contractor" has the same meaning as in RCW 48.44.035.2
Sec. 3. RCW 48.44.035 and 1997 c 212 s 1 are each amended to 3
read as follows: 4
(1) For purposes of this section ((only)) and section 2 of this 5
act, "limited health care service" means dental care services, vision 6
care services, mental health services, chemical dependency services, 7
pharmaceutical services, podiatric care services, and such other 8
services as may be determined by the commissioner to be limited 9
health services, but does not include hospital, medical, surgical, 10
emergency, or out-of-area services except as those services are 11
provided incidentally to the limited health services set forth in 12
this subsection. 13
(2) For purposes of this section ((only)) and section 2 of this 14
act, a "limited health care service contractor" means a health care 15
service contractor that offers one and only one limited health care 16
service. 17
(3) Except as provided in subsection (4) of this section, every 18
limited health care service contractor must have and maintain a 19
minimum net worth of three hundred thousand dollars.20
(4) A limited health care service contractor registered before 21
July 27, 1997, that, on July 27, 1997, has a minimum net worth equal 22
to or greater than that required by subsection (3) of this section 23
must continue to have and maintain the minimum net worth required by 24
subsection (3) of this section. A limited health care service 25
contractor registered before July 27, 1997, that, on July 27, 1997, 26
does not have the minimum net worth required by subsection (3) of 27
this section must have and maintain a minimum net worth of:28
(a) Thirty-five percent of the amount required by subsection (3) 29
of this section by December 31, 1997; 30
(b) Seventy percent of the amount required by subsection (3) of 31
this section by December 31, 1998; and 32
(c) One hundred percent of the amount required by subsection (3) 33
of this section by December 31, 1999. 34
(5) For all limited health care service contractors that have had 35
a certificate of registration for less than three years, their 36
uncovered expenditures shall be either insured or guaranteed by a 37
foreign or domestic carrier admitted in the state of Washington or by 38
another carrier acceptable to the commissioner. All such contractors 39
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shall also deposit with the commissioner one-half of one percent of 1
their projected premium for the next year in cash, approved surety 2
bond, securities, or other form acceptable to the commissioner.3
(6) For all limited health care service contractors that have had 4
a certificate of registration for three years or more, their 5
uncovered expenditures shall be assured by depositing with the 6
insurance commissioner twenty-five percent of their last year's 7
uncovered expenditures as reported to the commissioner and adjusted 8
to reflect any anticipated increases or decreases during the ensuing 9
year plus an amount for unearned prepayments; in cash, approved 10
surety bond, securities, or other form acceptable to the 11
commissioner. Compliance with subsection (5) of this section shall 12
also constitute compliance with this requirement. 13
(7) Limited health service contractors need not comply with RCW 14
48.44.030 or 48.44.037. 15
NEW SECTION. Sec. 4. A new section is added to chapter 48.44 16
RCW to read as follows: 17
(1) A dental insurer or third-party administrator may pay a claim 18
for reimbursement made by a dental care provider using a credit card 19
or electronic funds transfer payment method that imposes on the 20
provider a fee or similar charge to process the payment if:21
(a) The dental insurer notifies the provider, in advance, of the 22
potential fees or other charges associated with the use of the credit 23
card or electronic funds transfer payment method; 24
(b) The dental insurer offers the provider an alternative payment 25
method that does not impose fees or similar charges on the provider; 26
and 27
(c) The provider or a designee of the provider elects to accept a 28
payment of the claim using the credit card or electronic funds 29
transfer payment method. 30
(2) If a dental insurer contracts with a vendor to process 31
payments of dental providers' claims, the dental insurer shall 32
require the vendor to comply with the provisions of subsection (1)(a) 33
of this section. 34
(3) As used in this section, "dental insurer" means an insurer 35
that offers a policy or certificate of insurance or other contract, 36
that provides only a dental benefit. 37
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NEW SECTION. Sec. 5. The insurance commissioner may adopt any 1
rules necessary to implement sections 2 through 4 of this act.2
Sec. 6. RCW 48.44.495 and 2010 c 228 s 3 are each amended to 3
read as follows: 4
(1) Notwithstanding any other provisions of law, no contract of 5
any health care service contractor subject to the jurisdiction of the 6
state of Washington that covers any dental services, and no contract 7
or participating provider agreement with a dentist may:8
(a) Require, directly or indirectly, that a dentist who is a 9
participating provider provide services to an enrolled participant at 10
a fee set by, or at a fee subject to the approval of, the health care 11
service contractor unless the dental services are covered services, 12
including services that would be reimbursable but for the application 13
of contractual limitations such as benefit maximums, deductibles, 14
coinsurance, waiting periods, or frequency limitations, under the 15
applicable group contract or individual contract; nor16
(b) Prohibit, directly or indirectly, a dentist who is a 17
participating provider from offering or providing to an enrolled 18
participant dental services that are not covered services on any 19
terms or conditions acceptable to the dentist and the enrolled 20
participant. 21
(2) An employee benefit plan or health insurance policy must 22
provide that payment or reimbursement for a noncontracting provider 23
dentist is no less than the payment or reimbursement for a 24
contracting provider dentist.25
(3) For the purposes of this section, "covered services" means 26
dental services that are reimbursable under the applicable subscriber 27
agreement or would be reimbursable but for the application of 28
contractual limitations such as benefit maximums, deductibles, 29
coinsurance, waiting periods, or frequency limitations.30
NEW SECTION. Sec. 7. A new section is added to chapter 48.43 31
RCW to read as follows: 32
(1) The commissioner shall require health carriers, as defined in 33
RCW 48.43.743, offering dental only plans to submit information as 34
required by the commissioner, which shall include the current and 35
projected dental loss ratio for dental only plans and the components 36
of projected administrative expenses. 37
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(2) Unless otherwise determined by the commissioner, the 1
following items shall be deemed to be an administrative expense for 2
the purposes of calculating and reporting the dental loss ratio:3
(a) Financial administration expenses; 4
(b) Marketing and sales expenses; 5
(c) Distribution expenses; 6
(d) Claims operations expenses; 7
(e) Medical administration expenses, such as disease management, 8
care management, utilization review, and medical management 9
activities; 10
(f) Network operations expenses; 11
(g) Charitable expenses when the expense involves a nonprofit 12
affiliated with an insurance company; 13
(h) Board, bureau, or association fees; and 14
(i) State and federal tax expenses, including assessments.15
(3) The dental loss ratio shall be computed by dividing the total 16
dental payments by the total revenue for the plan.17
NEW SECTION. Sec. 8. A new section is added to chapter 48.43 18
RCW to read as follows: 19
(1) Health carriers, as defined in RCW 48.43.743, offering dental 20
only plans shall file their plan rates and any changes to group 21
rating factors that will be effective January 1st of the following 22
year by a date determined by the commissioner. 23
(2) The commissioner shall disapprove any proposed plan rates 24
that are excessive, inadequate, or unreasonable in relation to the 25
benefits charged, and shall disapprove any change to group rating 26
factors that are discriminatory or not actuarially sound.27
(3) A rate shall be presumptively disapproved as excessive by the 28
commissioner if a carrier files a rate change and:29
(a) The administrative expense component, not including taxes and 30
assessments, increases from the previous year's rate filing by more 31
than the most recent calendar year's increase in the dental services 32
consumer price index; 33
(b) The reported contribution to surplus exceeds 1.9 percent of 34
total revenue; or 35
(c) The dental loss ratio for the plan is less than 85 percent.36
(4)(a)(i) If the commissioner disapproves of a rate or group 37
rating factor submitted by a carrier under subsection (2) of this 38
section, the commissioner shall notify the carrier no later than 45 39
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days before the proposed effective date of the rate or group rating 1
factor. 2
(ii) A carrier may request a hearing within 10 days of receiving 3
notice of the disapproval. If a carrier requests a hearing, the 4
commissioner shall hold a hearing within 15 days of the request and 5
issue a decision within 30 days after the hearing. A carrier may not 6
implement the disapproved rate or group rating factor unless the 7
commissioner reverses the decision after the hearing.8
(b)(i) If a plan rate is presumptively disapproved under 9
subsection (3) of this section, the commissioner shall hold a public 10
hearing. 11
(ii) A carrier shall notify all employers and individuals covered 12
by the plan of the presumptive disapproval and that the disapproval 13
is subject to a public hearing. 14
(5)(a) If the annual dental loss ratio for a dental only plan 15
offered by a carrier is less than 85 percent, the carrier shall 16
refund the excess premium to its covered individuals and covered 17
groups. 18
(b) A carrier shall communicate to all individuals and groups 19
that were covered under plans during the relevant 12-month period 20
that such individuals and groups qualify for a refund on the premium, 21
or, if the individual or groups are still covered by the carrier, 22
that the individual or groups are eligible for a credit on the 23
premium for the subsequent 12-month period. 24
(c) The total of all refunds issued shall equal the amount of a 25
carrier's earned premium that exceeds the amount necessary to achieve 26
a medical loss ratio of 85 percent, calculated using data reported by 27
the carrier as prescribed by the commissioner in rule.28
(d) The commissioner may authorize a waiver or adjustment of the 29
refund requirements in this section only if it is determined that 30
issuing refunds would result in financial impairment for the carrier.31
Sec. 9. RCW 48.43.743 and 2015 c 9 s 2 are each amended to read 32
as follows: 33
(1) Each health carrier offering a dental only plan shall submit 34
to the commissioner on or before April 1st of each year as part of 35
the additional data statement or as a supplemental data statement the 36
following information for the preceding year that is derived from the 37
carrier's annual statement, including the exhibit of premiums, 38
enrollments, and utilization for the company at an aggregate level 39
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and the additional data to the annual statement , which must be based 1
on Washington data and may not include data from other states:2
(a) The total number of dental members; 3
(b) The total amount of dental revenue; 4
(c) The total amount of dental payments; 5
(d) The dental loss ratio that is computed ((by dividing the 6
total amount of dental payments by the total amount of dental 7
revenues)) as required in section 7 of this act; 8
(e) The average amount of premiums per member per month; and9
(f) The percentage change in the average premium per member per 10
month, measured from the previous year. 11
(2) A carrier shall electronically submit the information 12
described in subsection (1) of this section in a format and according 13
to instructions prescribed by the commissioner. 14
(3) The commissioner shall make the information reported under 15
this section available to the public in a format that allows 16
comparison among carriers through a searchable public website on the 17
internet. 18
(4) For the purposes of licensed disability insurers and health 19
care service contractors, the commissioner shall work collaboratively 20
with insurers to develop an additional or supplemental data statement 21
that utilizes to the maximum extent possible information from the 22
annual statement forms that are currently filed by these entities.23
(5) For purposes of this section, "health carrier," in addition 24
to the definition in RCW 48.43.005, also includes health care service 25
contractors, limited health care service contractors, and disability 26
insurers offering dental only coverage. 27
(6) Nothing in this section is intended to establish a minimum 28
dental loss ratio. 29
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