[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1809 Introduced in House (IH)]

112th CONGRESS
  1st Session
                                H. R. 1809

To amend the Employee Retirement Income Security Act of 1974 to ensure 
 health care coverage value and transparency for dental benefits under 
                          group health plans.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 10, 2011

     Mr. Andrews (for himself, Mr. Young of Alaska, and Mr. Gosar) 
 introduced the following bill; which was referred to the Committee on 
                      Education and the Workforce

_______________________________________________________________________

                                 A BILL


 
To amend the Employee Retirement Income Security Act of 1974 to ensure 
 health care coverage value and transparency for dental benefits under 
                          group health plans.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Dental Coverage Value and 
Transparency Act of 2011''.

SEC. 2. VALUE AND TRANSPARENCY REQUIREMENTS FOR DENTAL BENEFITS.

    (a) In General.--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:

``SEC. 716. VALUE AND TRANSPARENCY REQUIREMENTS FOR DENTAL BENEFITS.

    ``(a) In General.--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) Value.--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 benefits.--The 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 payments.--In 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) Transparency.--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 coding.--The 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) Fair payment terms.--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 networks.--A 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) Conforming Amendment.--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) Effective Date.--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.
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