Dental insurance.

25LSO-0622
2025
STATE OF WYOMING
25LSO-0622
Numbered
2.0

SENATE FILE NO. SF0159

Dental insurance.

Sponsored by: Senator(s) Jones, Barlow, Cooper and Crago and Representative(s) Wylie

A BILL

for

AN ACT relating to the insurance code; providing dental insurance requirements for billing and coding as specified; providing definitions; specifying applicability; and providing for an effective date.

Be It Enacted by the Legislature of the State of Wyoming:

Section 1
.

W.S. 26
‑
22
‑
505(a), (b) and by creating a new subsection (d) is amended to read:

26
‑
22
‑
505.

Dental insurance; limitation on fee schedules for noncovered services; definition; applicability.

(a)

No person
or entity
contracting with dentists to provide coverage or reimbursement for dental services shall
:

(i)

R
equire a dentist to provide services at a fee set by the contract, a policy or a certificate unless the services are covered services by the terms of the contract, policy or certificate
;
.

(ii)

Based on the provider's contracted fee for covered services, use downcoding in a manner that prevents a provider from collecting a fee for actual services performed as specified in subsection (b) of this section;

(iii)

Utilize the practice of bundling in a manner where a procedure code is labeled as nonbillable to the patient unless, under generally accepted practice standards, the procedure code is for a procedure that may be provided in conjunction with another procedure;

(iv)

Adjust a procedure code submitted by a dentist unless the following conditions are met:

(A)

The change is consistent with the person's policies;

(B)

The person has sufficient information to make the change;

(C)

The explanation of benefits provided to the subscriber shall include the reason for the downcoding and citation of the person's applicable policy.

(v)

Allow the explanation of benefits to state or infer that the code billed by the dentist or other health care provider was inappropriate unless there is evidence that the code listed on the claim by the dentist or provider is not related to the procedure performed;

(vi)

Allow the explanation of benefits to state or infer that the dentist or other health care provider's charge was excessive unless there is clear evidence that the charge was substantially higher than the dentist's regular fee;

(vii)

The person shall disclose in its provider contracts, on its website or both the specific downcoding policies that the dental service contractor reasonably expects to be applied to the provider or provider's services on a routine basis as a matter of policy.

(b)

For purposes of this section
:
,

(i)

"
covered
Covered
services" means services reimbursable under the contract, policy or certificate, subject to customary contractual limitations on benefits including such items as deductibles, waiting periods, frequency limitations or charges over the benefit maximum
;
.

(ii)

"Bundling" means the practice of combining distinct dental procedures into one (1) procedure for billing purposes;

(iii)

"Downcode" or "downcoding" means the adjustment of a claim submitted to a dental health benefit plan to a less complex or lower cost procedure code.

(d)

Nothing in this section shall preclude a dentist who has written informed consent of a patient from collecting monies for services downcoded or denied at rates published in the dentist's fee schedule.

Section 2.

W.S. 26
‑
22
‑
505(c) is repealed.

Section 3.

This act applies to contracts, policies or certificates entered into or issued on or after July 1, 2025. Nothing in this act is construed to impair any existing contracts, policies or certificates entered into or issued before July 1, 2025.

Section 4.

This act is effective July 1, 2025
.

(END)

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SF0159