1.This Act may be cited as the Dental Coverage Value and Transparency Act of 2010
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2.Value and transparency requirements for dental benefits
(a)Subpart B of part 7 of subtitle A of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:
716.Value and transparency requirements for dental benefits
(a)The requirements of this section shall apply to group health plans insofar as they provide dental benefits (including, notwithstanding section 732(c)(1), limited scope dental benefits (described in section 733(c)(2))), directly, through health insurance coverage, or otherwise.
(b)In order to ensure that participants and beneficiaries in a group health plan receive full value from dental benefits, the plan shall meet the following requirements:
(1)Uniform coordination of benefitsThe plan shall provide for coordination of benefits in a manner so that the plan pays the same amount regardless of other coverage for such benefits so long as the total amount paid does not exceed 100 percent of the amount of the applicable claim. Such coordination shall be effected consistent with such rules as the Secretary establishes, based upon similar model regulations developed by the National Association of Insurance commissioners.
(2)Equity for out-of-network providers through assignment of benefits and comparable paymentsIn the case of a plan that provides dental benefits through a network of providers, the plan shall—
(A)permit a participant or beneficiary to designate payment of dental benefits to a provider who is not participating in the network;
(B)provide the same dollar amount of coverage for a given procedure regardless of whether the provider of the procedure is participating in the network; and
(C)not permit the application of the plan’s or network’s fee schedule to services for which no benefits or reimbursement are provided.
(c)In order to ensure transparency in the provision of dental benefits to participants and beneficiaries in a group health plan, the plan shall meet the following requirements:
(1)Prohibition of bundling and down codingThe plan shall not—
(A)systematically combine distinct dental procedures codes in a manner that results in a reduced benefit under the plan; or
(B)provide for a change in the benefit code to a less complex (or lower cost) procedure than was reported if such actions are inconsistent with the current dental terminology (CDT) or, for a provider participating in a network, inconsistent with the terms of the network participation agreement.
(2)The plan shall—
(A)provide for payment of interest (at a rate specified by the Secretary) or other penalty for clean claims paid more than 30 days after the date of their submission;
(B)not seek collection of overpayments more than 90 days after the date of the overpayment; and
(C)not recover overpayments for a dental procedure by withholding payments for unrelated procedures.
(3)Transparency in use of lease networksA plan may use a network that is leased by a health insurance issuer or other entity to another such issuer or entity (where such leasing is permitted by the contract between a provider and the issuer or other entity) only if the contract language describes in a manner understandable to the average dental provider the terms of such leasing, .
(b)The table of contents of such Act is amended by inserting after the item relating to section 715 the following new item:
Sec. 716. Value and transparency requirements for dental benefits..
(c)The amendments made by this section shall apply to plan years beginning more than 1 year after the date of the enactment of this Act.