117 S1793 IS: Dental and Optometric Care Access Act of 2021 U.S. Senate 2021-05-24 text/xml EN Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.

II117th CONGRESS1st SessionS. 1793IN THE SENATE OF THE UNITED STATESMay 24, 2021Mr. Manchin (for himself and Mr. Cramer) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and PensionsA BILLTo amend title XXVII of the Public Health Service Act to improve health care coverage under vision and dental plans, and for other purposes.

1.

Short title

This Act may be cited as the Dental and Optometric Care Access Act of 2021 or the DOC Access Act of 2021.

2.

Improving health care coverage under vision and dental plans

(a)

PHSA

(1)

In general

Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–111 et seq.) is amended by adding at the end the following:

2799A–11.

Improving coverage under vision and dental plans

(a)

In general

Under a group health plan or individual or group health insurance coverage (including such a plan or coverage offering limited scope dental or vision benefits), the following shall apply:(1)

Payment amounts from covered persons

(A)

In general

The plan or coverage shall provide that, with respect to a doctor of optometry, doctor of dental surgery, or doctor of dental medicine that has an agreement to participate in the plan or coverage and that provides items or services that are not covered services under the plan or coverage to a person enrolled under such plan or coverage, the doctor may charge the enrollee for such items or services any amount determined by the doctor that is equal to, or less than, the usual and customary amount that the doctor charges individuals who are not so enrolled for such items or services.(B)

Items or services considered covered by a plan

For purposes of subparagraph (A), an item or service shall be considered, with respect to a plan or coverage, to be covered services under the plan or coverage only if the item or service is an item or service with respect to which the plan or coverage is obligated to pay an amount that is reasonable and is not nominal or de minimis. (C)

Exception for dental cleaning

For purposes of subparagraph (A), a doctor of dental surgery or doctor of dental medicine that has an agreement to participate in the plan or coverage may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan or coverage. (2)

Duration of limited scope vision and dental plans

In the case of an agreement between such a doctor and such a plan or coverage that offers limited scope dental or vision benefits—(A)the agreement may be extended for a term longer than 2 years only with the prior acceptance of the doctor for each such term extension; and(B)the agreement may be extended for unlimited terms, subject to subparagraph (A).(3)

No restrictions on choice of laboratories

The plan or coverage may not, directly or indirectly, restrict or limit, such a doctor’s choice of laboratories or choice of source and suppliers of services or materials provided by the doctor to an individual who is enrolled under the plan or coverage.(b)

Private right of action

In addition to any other remedies under State or Federal law, a person adversely affected by a violation of this subsection may bring action for injunctive relief against a plan described in subsection (a) and, upon prevailing, in addition to such injunctive relief shall recover monetary damages of no more than $1,000 for each day found to be in violation plus attorney’s fees and costs. The district courts of the United States shall have exclusive jurisdiction of civil actions brought under this subsection.(c)

Relationship to exception for limited, excepted benefits

Section 2722(c)(1) shall not apply with respect to the requirements of this section.(d)

Election To be excluded

(1)

In general

If a doctor of optometry, doctor of dental surgery, or doctor of dental medicine to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan or coverage shall not apply to such plan or coverage for such period, as described in paragraph (2). (2)

Period of election

An election under paragraph (1)—(A)shall apply for a single specified plan year;(B)may be extended through subsequent elections under this subsection; and (C)shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). (e)

Definitions

In this section:(1)The term covered services means dental care or vision care services for which reimbursement is available under a plan or coverage contract, or for which reimbursement would be available but for the application of contractual limitations, including deductibles, copayments, coinsurance, waiting periods, lifetime maximum, frequency limitations, and alternative benefit payments. (2)The terms doctor of dental surgery and doctor of dental medicine mean a doctor of dental surgery or of dental medicine, as applicable, who is legally authorized to practice dentistry by the State in which the doctor performs such function and who is acting within the scope of the license of the doctor when performing such functions.(3)The term doctor of optometry means a doctor of optometry who is legally authorized to practice optometry by the State in which the doctor so practices.

.(2)

Conforming amendment

Section 2722(c)(1) of the Public Health Service Act (42 U.S.C. 300gg–21(c)(1)) is amended by striking The requirements and inserting Subject to section 2799A–11, the requirements.(b)

ERISA

(1)

In general

Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following:

726.

Improving coverage under vision and dental plans

(a)

In general

Under a group health plan or group health insurance coverage (including such a plan or coverage offering limited scope dental or vision benefits), the following shall apply:(1)

Payment amounts from covered persons

(A)

In general

The plan or coverage shall provide that, with respect to a doctor of optometry, doctor of dental surgery, or doctor of dental medicine that has an agreement to participate in the plan or coverage and that provides items or services that are not covered services under the plan or coverage to a person enrolled under such plan or coverage, the doctor may charge the enrollee for such items or services any amount determined by the doctor that is equal to, or less than, the usual and customary amount that the doctor charges individuals who are not so enrolled for such items or services.(B)

Items or services considered covered by a plan

For purposes of subparagraph (A), an item or service shall be considered, with respect to a plan or coverage, to be covered services under the plan or coverage only if the item or service is an item or service with respect to which the plan or coverage is obligated to pay an amount that is reasonable and is not nominal or de minimis. (C)

Exception for dental cleaning

For purposes of subparagraph (A), a doctor of dental surgery or doctor of dental medicine that has an agreement to participate in the plan or coverage may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan or coverage. (2)

Duration of limited scope vision and dental plans

In the case of an agreement between such a doctor and such a plan or coverage that offers limited scope dental or vision benefits—(A)the agreement may be extended for a term longer than 2 years only with the prior acceptance of the doctor for each such term extension; and(B)the agreement may be extended for unlimited terms, subject to subparagraph (A).(3)

No restrictions on choice of laboratories

The plan or coverage may not, directly or indirectly, restrict or limit, such a doctor’s choice of laboratories or choice of source and suppliers of services or materials provided by the doctor to an individual who is enrolled under the plan or coverage.(b)

Private right of action

In addition to any other remedies under State or Federal law, a person adversely affected by a violation of this subsection may bring action for injunctive relief against a plan described in subsection (a) and, upon prevailing, in addition to such injunctive relief shall recover monetary damages of no more than $1,000 for each day found to be in violation plus attorney’s fees and costs. The district courts of the United States shall have exclusive jurisdiction of civil actions brought under this subsection.(c)

Relationship to exception for limited, excepted benefits

Section 732(c)(1) shall not apply with respect to the requirements of this section.(d)

Election To be excluded

(1)

In general

If a doctor of optometry, doctor of dental surgery, or doctor of dental medicine to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan or coverage shall not apply to such plan or coverage for such period, as described in paragraph (2). (2)

Period of election

An election under paragraph (1)—(A)shall apply for a single specified plan year;(B)may be extended through subsequent elections under this subsection; and (C)shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). (e)

Definitions

In this section:(1)The term covered services means dental care or vision care services for which reimbursement is available under a plan or coverage contract, or for which reimbursement would be available but for the application of contractual limitations, including deductibles, copayments, coinsurance, waiting periods, lifetime maximum, frequency limitations, and alternative benefit payments. (2)The terms doctor of dental surgery and doctor of dental medicine mean a doctor of dental surgery or of dental medicine, as applicable, who is legally authorized to practice dentistry by the State in which the doctor performs such function and who is acting within the scope of the license of the doctor when performing such functions.(3)The term doctor of optometry means a doctor of optometry who is legally authorized to practice optometry by the State in which the doctor so practices.

.(2)

Conforming amendment

Section 732(c)(1) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1191a(c)(1)) is amended by striking The requirements and inserting Subject to section 726, the requirements.(3)

Clerical amendment

The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.) is amended by inserting after the item relating to section 725 the following:Sec. 726. Improving coverage under vision and dental plans..(c)

IRC

(1)

In general

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following:

9826.

Improving coverage under vision and dental plans

(a)

In general

Under a group health plan (including such a plan offering limited scope dental or vision benefits), the following shall apply:(1)

Payment amounts from covered persons

(A)

In general

The plan shall provide that, with respect to a doctor of optometry, doctor of dental surgery, or doctor of dental medicine that has an agreement to participate in the plan and that provides items or services that are not covered services under the plan to a person enrolled under such plan, the doctor may charge the enrollee for such items or services any amount determined by the doctor that is equal to, or less than, the usual and customary amount that the doctor charges individuals who are not so enrolled for such items or services.(B)

Items or services considered covered by a plan

For purposes of subparagraph (A), an item or service shall be considered, with respect to a plan, to be covered services under the plan only if the item or service is an item or service with respect to which the plan is obligated to pay an amount that is reasonable and is not nominal or de minimis. (C)

Exception for dental cleaning

For purposes of subparagraph (A), a doctor of dental surgery or doctor of dental medicine that has an agreement to participate in the plan may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan. (2)

Duration of limited scope vision and dental plans

In the case of an agreement between such a doctor and such a plan that offers limited scope dental or vision benefits—(A)the agreement may be extended for a term longer than 2 years only with the prior acceptance of the doctor for each such term extension; and(B)the agreement may be extended for unlimited terms, subject to subparagraph (A).(3)

No restrictions on choice of laboratories

The plan may not, directly or indirectly, restrict or limit, such a doctor’s choice of laboratories or choice of source and suppliers of services or materials provided by the doctor to an individual who is enrolled under the plan.(b)

Private right of action

In addition to any other remedies under State or Federal law, a person adversely affected by a violation of this subsection may bring action for injunctive relief against a plan described in subsection (a) and, upon prevailing, in addition to such injunctive relief shall recover monetary damages of no more than $1,000 for each day found to be in violation plus attorney’s fees and costs. The district courts of the United States shall have exclusive jurisdiction of civil actions brought under this subsection.(c)

Relationship to exception for limited, excepted benefits

Section 9831(c)(1) shall not apply with respect to the requirements of this section.(d)

Election To be excluded

(1)

In general

If a doctor of optometry, doctor of dental surgery, or doctor of dental medicine to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan shall not apply to such plan for such period, as described in paragraph (2). (2)

Period of election

An election under paragraph (1)—(A)shall apply for a single specified plan year;(B)may be extended through subsequent elections under this subsection; and (C)shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). (e)

Definitions

In this section:(1)The term covered services means dental care or vision care services for which reimbursement is available under a plan contract, or for which reimbursement would be available but for the application of contractual limitations, including deductibles, copayments, coinsurance, waiting periods, lifetime maximum, frequency limitations, and alternative benefit payments. (2)The terms doctor of dental surgery and doctor of dental medicine mean a doctor of dental surgery or of dental medicine, as applicable, who is legally authorized to practice dentistry by the State in which the doctor performs such function and who is acting within the scope of the license of the doctor when performing such functions.(3)The term doctor of optometry means a doctor of optometry who is legally authorized to practice optometry by the State in which the doctor so practices.

.(2)

Conforming amendment

Section 9831(c)(1) of the Internal Revenue Code of 1986 is amended by striking The requirements and inserting Subject to section 9826, the requirements.(3)

Clerical amendment

The table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following: Sec. 9826. Improving coverage under vision and dental plans..

3.

Exclusive applicability of State law

Notwithstanding any amendment made by this Act, State law that directly affects any standard or requirement relating to health insurance issuers and dental or vision benefit plans, shall have exclusive application and the amendments made by this Act shall not apply to the extent that such State law conflicts with such amendments. The State shall retain exclusive jurisdiction over health insurance issuers and limited scope dental or vision benefit plans that are directly governed by such State.