The bill prohibits plans from imposing arbitrary waiting periods and denies compensation for existing conditions. I need a rate review and her ERISA notification.
Two CDA-backed bills introduced this month, including one authored by Rep. Jim Wood (DDS), call for the CDA to hold dental insurance plans accountable and move toward more meaningful dental coverage. legislative efforts continue.
The bill would ensure that health insurance plans comply with federal and state rules that protect patients from unreasonable rate changes, arbitrary waiting periods for full benefits to become available, and denial of coverage. It addresses the fact that dental insurance plans still lack major consumer protections and adequate oversight, even though they must. For example, due to existing conditions.
CDA DDS President John Blake said: “Waxes and loopholes have allowed dental plans to continue operating in a ‘wild west’ environment with little oversight or regulation to ensure they provide meaningful benefits to consumers. As we continue to move the needle to increase access to healthcare, now is the time to tame the Wild West and demanding accountability through these two bills is a great place to start. . “
Eliminate loopholes that deny coverage and increase out-of-pocket costs
AB 1048 Rep. Buffy Wicks (D-Oakland) provides dental insurance plans with some of the important protections that the Affordable Care Act brought to health insurance plans, denying patient coverage and reducing out-of-pocket costs. Eliminate loopholes that lead to growth. .
Specifically, the bill would look like this:
- Prohibits dental benefit plans from imposing arbitrary waiting periods before patients receive full benefits.
- Prohibits dental benefit plans from denying claims related to a patient’s existing dental condition.
- Requires state review of dental insurance rates to protect consumers from unfair or unreasonable charges.
Arbitrary waiting periods, such as those currently required by some commercial dental plans, can range from 3 months to 1 year, and even when clinically necessary, patients may have access to procedures such as root canals and crowns. limited ability to access key services of
Services related to missing teeth or cleft palate should not be denied
The ACA banned waiting periods and removed existing conditional clauses to allow patients full and unhindered access to medical benefits, but dental benefit plans would not work under such clauses. . Instead, you are free to impose waiting periods for necessary dental care or refuse to pay for services related to pre-existing dental conditions. Common examples include dental insurance related to genetic conditions such as cleft palate and “missing tooth” provisions for teeth lost before dental treatment has begun.
“Ensuring these basic patient protections in a dental plan benefits patients in need and ensures timely access to dental care for paying consumers,” Dr. Blake said. added.
In addition, by requiring dental benefit plans to have their rates reviewed by their respective state regulators (either the California Department of Health or the Department of Managed Health Care), the state will be able to determine how the plans determine their rates. You can get more insight into what you are setting or changing. This protects the consumer from unfair or unreasonable charges.
recently Reporting medical expenses shows that out-of-pocket costs for dental services will increase 16% in 2021, and a new study from the California Health Care Foundation found that 38% of Californians said their family members skipped dental care last year due to costs. It turns out that there is The bill will increase oversight to ensure consumers receive the value of their dental premiums.
These changes ensure that state-regulated dental benefit plans work for patients and dentists, but protect self-funded ERISA plans that states, including California, do not have the authority to regulate. loopholes remain. Here comes his second bill, sponsored by the CDA.
Takes the hassle out of the ERISA plan billing process
Most dental benefit plans are “fully insured” and are regulated at the state level by the Managed Health Care Department or the California Department of Insurance. Fully insured plans must comply with all California rules and regulations. However, some employers offer self-insurance plans. These plans are regulated at the federal level under the Employee Retirement Income Security Act of 1974, known as ERISA, and are not subject to state level rules and regulations.
An estimated 40% of Californians have a “self-insured” dental benefit plan that is exempt from state laws and regulations. Differences between California and federally regulated plans can be extensive, and ERISA plans are not required to comply with California law, making the billing process difficult and frustrating for both patients and providers. There is likely to be.
Still, steps can be taken at the state level to make plans more transparent and protect patients.
Congressman Jim Wood (D-Healdsburg), AB 952 by DDS, was to introduce two such measures. that is:
- When providers determine patient eligibility and benefits, dental insurance plans must disclose whether the subscriber’s plan is subject to state (DMHC or CDI) or federal (ERISA) regulation .
- A membership card, coverage card, or other document issued by a dental plan to a registrant must state whether the registrant’s plan is subject to state or federal regulation.
“It’s important that patients and providers are aware of which laws apply to their patients’ dental plans,” says Asm. wood. “Instead, what we now have is a clear lack of criteria that the plan must meet and where patients and dentists can go to resolve conflicts with the plan. The ERISA Notice will also provide clarity to the millions of Californians enrolled in these plans and help ease the complex billing process for dental offices.”
Building on Multi-Year Advocacy Progress
These bills follow some successful legislation sponsored by the CDA in recent years to improve dental planning.
One of the more recent ones was Parliamentary Bill 954, also made by Asm. Wood will take effect in 2020, requiring dental plans to be more transparent about leasing dental networks.
CDA-sponsored Senate Bill 1008 was passed in 2018 by requiring plans to use a uniform matrix to disclose benefits, including eligible services, reimbursement levels, estimated subscriber cost shares, limitations and exceptions. , increased transparency. The regulatory process was delayed by the COVID-19 pandemic, but as of this year, dental plans are providing this standardized information to educate registrants and enable consumers to make valid comparisons of plans. need to do it.
CDA was also behind First Bill in California The state requires dental plans to submit standardized annual medical loss rate (MLR) reports so that patients can understand the value of their dental plans (rather than administrative costs and benefits of the plan). , the amount of premium income actually spent on patient care). ).
MLR information collected through CDA-sponsored invoices strongly validates the lack of value in dental plans and continues to strengthen the CDA’s ongoing endorsement of dental insurance. As part of this work, the CDA will oversee the implementation and effectiveness of new legislation establishing his MLR requirements for dental plans in Massachusetts.
“The CDA has a long history of supporting MLR policies as part of creating more standardized requirements for dental plans that provide people with more meaningful insurance,” said Dr. Blake. “Currently, there are no floors for plans and benefits sold by dental insurers. MLR requirements, combined with other reforms that establish appropriate floors, will ultimately provide the most value to patients and dentists.” The CDA will continue to be strategic and thoughtful as it pursues many of the reforms necessary to make dental insurance a long-term quality product.”
All this work complements the CDA’s legal challenge to Delta Dental of California’s adjustments to the Premier and PPO Provider Agreements, which took effect January 1.
The CDA provides updates on bills and legal challenges in its newsroom and weekly member newsletter, Inside California Dentistry.
