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