June 2015


GRW Updates as State Legislative Sessions Adjourn – Loss Rations, Network Adequacy & More

As most states have adjourned their legislative sessions, the Government Relations Workgroup (GRW) can share updates on some of the more noteworthy 2015 priority bills. The group met twice monthly over five months to discuss 200+ priority bills offered in state legislatures. The following are a few of the legislative proposals the GRW discussed.

NADP members can view all priority bills and notes from the GRW calls on the GR Grid updated regularly on the Advocacy Resources webpage. Members can also receive updates and discuss developments in the Dental Interact (DI) Government Relations Open Forum.

Loss Ratios

WA HB 1002Enacted: On April 17, Governor Inslee approved Washington House Bill 1002, which includes two primary sections: a) to require carriers offering dental-only plans to submit information on loss ratios and b) to prohibit dental plans from denying coverage for treatment of emergency dental conditions that would otherwise be covered on the basis that the services were provided on the same day of examination and diagnosis. The dental loss ratio (DLR) submissions mirror similar reports required of medical carriers in the state, but will be made publicly available in a searchable format available online here. The legislation as passed represents months of collaboration and negotiation between stakeholders and dental carriers. The original bill would have required dental plans to meet current MLR standards; applied guaranteed renewability and availability standards to dental; prohibited carriers from denying certain services; and required similar reimbursement for providers in and out of network. The law becomes effective January 1, 2017, with reports on 2016 loss ratio data presumably due April 1, 2017. Further discussion with the Office of the Insurance Commissioner (OIC) may further define terms and calculations of certain terms in the legislation, such as “revenue” and “dental payments.”


MA HB 951Pending: HB 951 would establish a dental loss ratio of 90 percent through December 19, 2016, then raising to 95 percent after January 2017. (The ACA medical loss ratio provision is 85 percent for large groups.) Additional sections would require dental benefit plans to cover 100 percent of preventive and diagnostic services for those individuals aged 18 and older. For individuals under 18, the bill would require dental plans to cover 100 percent of preventive and diagnostic services and basic restorative services. Annual maximums less than $1,000 would be prohibited. Also, any unused annual maximum would be required to be carried over to the next calendar year. Waiting limits on preventive and diagnostic services would be prohibited. The bill also includes a brief non-covered services (NCS) provision without any definition for covered service. Futher, the bill gives the Commissioner authority to disapprove any reimbursement fee methodologies that do not increase reimbursements by at least the most recent calendar year’s percentage increase in the New England dental CPI. There are also provisions requiring rate review for dental plans.

As background, the Massachusetts state legislature approved the idea for a special commission to study dental insurance after a non-covered services (NCS) bill had been vetoed by the Governor. In 2013-14, the Commission studied carrier contracts, reimbursement, dental fees and other aspects of dental coverage. The Commission’s report to the legislature included recommendations on mandated benefits, quality standards, reimbursement for specialty dentists, loss ratios and NCS.

MA HB 951 appears to be the state dental society’s response to the issues addressed by the Commission and includes elements from prior year bills sponsored by the dental association.

The bill has not moved since introduction. NADP and the GRW have been in contact with carriers domiciled in the state, who are hopeful this measure will not advance. Carriers and experts in the state have asked national groups to hold off commenting for now as it could be viewed negatively by legislators and even cause them to dig in their heels in response to outside pressure.

In early March, the House Corporations Committee held a hearing on the measure where minimal support was offered and issuers testified in opposition. The bill has been held for further study although could be brought up at a later date. As in Massachusetts, carriers and experts in the state have asked national groups to hold off commenting. The GRW will continue to monitor this measure and stay in contact with carriers in the state.


RI HB 5700Pending: The bill would require health care service plans that issue specialized plans covering dental services to file medical loss ratio (MLR) annual reports with the department of health. The report would be organized by market and product type and contain the same information required in the federal MLR Annual Reporting Form. It is the intent of the general assembly that the data reported would be used in adopting a medical loss ratio standard for dental plans that would take effect no later than 1/1/2019. The first report would be due 9/30/2016. The bill directs the Office of the Health Insurance Commissioner (OHIC) to make available to the public all of the data provided. The bill would not apply to contracts offered for services provided by RIteCare or Rhode Island’s Medicaid program.

In early March, the House Corporations Committee held a hearing on the measure where minimal support was offered and issuers testified in opposition. The bill has been held for further study although could be brought up at a later date. As in Massachusetts, carriers and experts in the state have asked national groups to hold off commenting. The GRW will continue to monitor this measure and stay in contact with carriers in the state.


Provider Directories & Network Adequacy

Responding to consumer complaints on network access and accuracy of provider listings, legislators and regulators in several states took steps to establish or tighten standards on provider directories generally aimed at medical plans but are also applying to dental plans as well. The Government Relations Workgroup (GRW) has discussed efforts in several states and anticipates a growing trend. Arguably the most worrisome element of the proposals is a requirement that plans drop dentists from directories if they have not submitted a claim within the past three months. Amendments in most cases have eliminated these provisions except in California where advocacy is ongoing.


CA SB 137Pending: SB 137 requires health care service plans and insurers subject to regulation by the commissioner for services at alternative rates to make a provider directory available on its Internet Web site and to update the directory weekly. The bill requires the Department of Managed Health Care and the Department of Insurance to develop a standard provider directory template. Amendments have changed the requirement regarding claims inactivity: The plan is directed to contact the provider that has not submitted a claim within the past 3 months for primary care providers or 6 months for specialty care providers to determine whether the provider is accepting patients or referrals from the plan. This requirement does not apply to claims or encounter data from new primary care providers in the first three months, or new specialty care providers in the first six months, of the contract. Concerns remain regarding the administration of such provider contact and the impact to large networks and new carriers. California Association of Dental Plans (CADP) and carrier activity is ongoing.


IL SB 750Pending: As originally proposed, SB 750 would require QHP and dental plan issuers to update directories monthly and in a manner that accommodates individuals with disabilities. The original bill would have also required plans to remove inactive network participants from the directory with “active” being defined as having filed a claim for a patient enrolled with the dental plan at least once in the previous 3-month period. Since then, Senate amendments have deleted provisions to require dental plans to remove providers from directories if they have not filed a claim within a prior 3-month period. The version considered by the Assembly would require dental plans to note whether a provider is accepting new patients at each of the specific locations listed in the directory. Providers are instructed to notify plans of any changes to their information, and plans are then required to update directories within 10 business days. SB 750 has been approved by both the House and Senate.


MO SB 383Died: The bill would have required any health insurer engaged in the act of contracting with providers for the delivery of dental services, or the selling or assigning of dental network plans, to make updates to their electronic and paper provider materials available to plan members or other potential plan members within 60 days of being notified of a changes by participating providers. Failure to comply with the requirements of this section may be subject to penalties under Section 374.049 as a level one violation. The bill would have required dental carriers to make sure their participating provider information is accurate if there had been one year of billing inactivity.

The bill passed the Senate small business, insurance and industry committee, but did not get much other attention before the legislature adjourned in late May.


HCR, EHB & Exchanges


CA SB 125Enacted: SB 125 requires annual health insurance enrollment periods under the Affordable Care Act extend from November 1, of the preceding calendar year, to January 31 of the benefit year, inclusive. Amendments made in the Assembly in early May revised the definition of “small employer” for Plan Year 2016 to require the use of the full-time equivalent employee counting method for determining employer size rather than existing law, which requires the calculation be based on “at least 50 percent of its working days” during the preceding year. California and other states have addressed the definition of small group and counting methodologies in legislation and regulatory notices, which the GRW is in the midst of tracking for member use.


OR SB 523Enacted: Signed by the Governor on June 26, SB 523 requires issuers to notify any provider that an enrollee is in a grace period if the provider requests the information from the insurer regarding eligibility, coverage or benefits. Insurers will be required to pay a claim for reimbursement if performed during the grace period for an enrollee who is subsequently terminated for nonpayment of premium if: (a) the issuer fails to notify the provider as required; (b) the service is covered by the enrollee’s plan; and (c) the provider requests the information not more than seven business days before providing the service and the insurer provides the information to the health care provider no later than two business days after the date of the provider’s request. Although dental plans on Exchanges may receive subsidies to a far lesser extent than QHPs (and thus be less likely to grant the required grace periods), this bill could still impact plans in those few cases and should be reviewed.


HI HB 174Pending: HB 174, approved by both chambers of the Hawaii legislature, would require individual and group health plans to provide coverage for medically necessary orthodontic services for the treatment of orofacial anomalies resulting from birth defects or syndromes to individuals under 26 years age. Legislators included amendments to exempt limited scope dental benefits from application.


NY SB 5972Pending: SB 5972 would make pregnancy a qualifying event on the state’s Marketplace—New York State of Health. The bill has passed both chambers of the legislature, and if signed, would go into effect in January 2016. It allows a pregnant woman to enroll with an effective date of the first of the month in which her pregnancy is confirmed. Under the ACA and HHS rules, birth not pregnancy triggers a qualifying event. New York’s Exchange would be the first to implement such provision.


Non-Covered Services

AL SB 296Enacted: With SB 296 enacted, Alabama became the 37th state to pass a measure on non-covered services (NCS). The final bill text included an amendment to align the definition of “covered services” with the NCOIL model act.


OH HB 95Pending: Ohio House Bill 95 passed the House June 10 by a vote of 61-33 and has been referred to the Senate Insurance Committee. The General Assembly will break for summer recess at the end of June and is likely to return in September.

The bill’s prohibition on non-covered services is in Ohio’s Health Care Contract Law, but the bill also makes the inclusion of non-covered services policies in dental contracts an unfair or deceptive practice in the business of insurance. This is highly unusual, as it is duplicative and makes inclusion of non-covered services policies in dental contracts a quasi-criminal offense. This is also a departure from the NCOIL model act banning fee schedules for uncovered dental services. HB 95 also departs from the NCOIL model by prohibiting voluntary non-covered services agreements.

Interested carriers are encouraged to contact members of the Senate Insurance Committee with concerns on the measure. Contact information for Committee members is online here.


NE LB 553Died: Nebraska already has an NCS provision in statute which doesn’t include a definition for “covered services.” LB 553 proposed a definition that would allow dental providers to charge patients fees higher than the discounted rate for services provided after the patient reaches a frequency limitation or annual maximum. NADP opposed this definition in comments. During a Banking, Commerce and Insurance Committee hearing in February, insurance carriers effectively communicated that the bill as drafted is anti-consumer and should be amended to align with NCOIL language in order to be consistent with other state approaches. In spite of support of the state dental association, the bill did not get additional attention before the legislature adjourned in May.


VT SB 19Died: SB 19 included a definition for “covered services” that aligned with the NCOIL model. It would have applied to both separately offered dental plans and health plans offering embedded dental services. The bill did not move out of the Committee on Finance before the legislature adjourned in May.


Reasonable Assurance


AR SB 927Enacted: On April 6, Arkansas Senate Bill 927 became law and clarifies the federal requirement that medical carriers offer all 10 essential health benefits, including pediatric oral services, outside the Exchanges in the small group and individual market. However, under the law, a medical carrier on or off the Exchange will be considered to have “reasonable assurance” the essential dental benefits are provided if (1) at least one qualified dental plan that offers those benefits is available and (2) a qualified health plan prominently discloses at the time of the purchase on a form approved by the Insurance Commissioner that the qualified health plan does not provide such coverage. SB 927 appears to align with a 2013 Insurance Department Bulletin on this topic. Read more about other state interpretations of reasonable assurance.


Provider Requirements & Contracts

LA HB 257Enacted: Within Louisiana credentialing statutes, HB 257 changes the definition of a “health care provider” to specifically include a licensed dentist. The law also changes the definition of a “health insurance issuer” to specifically include a dental benefit plan, including an entity defined as a dental service contractor in present law. The law provides that once a provider has been credentialed by an issuer for any location in the state, the provider shall be considered credentialed for all locations at which that provider may legally practice medicine or dentistry in this state. Insurers are prohibited from requiring recredentialing for additional locations. Credentialing for any additional location will be effective immediately upon receipt by the issuer of written notice from the provider. While the bill was under consideration, amendments were made to clarify that providers must give notice not less than 30 days prior to the time at which they begin practicing at any additional location.


ID SB 1062Enacted: Titled the Idaho Direct Primary Care Act, SB 1062 would confirm that direct patient-provider arrangements that satisfy the bill do not constitute insurance. Dental services can also be provided under these arrangements and not be regulated as insurance. However, the law limits those services to preventive or diagnostic dental treatment.



CO HB 1191Enacted: In 2008, the general assembly enacted SB 08-138, establishing the “Physician designation disclosure act” to impose certain standards and requirements on health care entities that assign designations to physicians as an assessment or measurement of the care or clinical performance of physicians. The bill adds dentists to the act, thereby imposing those same standards and requirements when health care entities assign designations to dentists, and changes the name of the act to the “Health care provider designation disclosure act.” Designations are awards, assignments, characterizations or representation of cost efficiency, quality or other measurement of care or clinical performance with the use of a grade, star, tier, rating, profile or other form. “Health care entity” is defined as any carrier or other entity that provides a plan of health care coverage to beneficiaries under a plan. Minimum standard rules on what a designation should include are established (i.e. performance measures on quality should be based on national standards). Disclosure of the designation methodology required upon request. Appeals must be allowed.


AL SB 295Died: This bill would have prohibited a health insurance entity from establishing a quality rating system for dentists using cost of services. This bill would have established allowable criteria for a quality rating system.



CA AB 1163Pending: This bill would prohibit and define a material change made to terms and conditions of a contract between a health insurer and an agent or broker, from becoming effective until the plan or insurer has delivered to the agent or broker written or electronic notice of the change or changes to the contract, within a specified time period (at least 60 days prior to effective date of change). Carriers and the California Association of Dental Plans (CADP) have been discussing with the sponsor the definition of “material change.”




NV AB 486Enacted: The law revises provisions governing the budget and accounts of the Division of Insurance. Regarding fees and resulting funds paid by insurers, the law abolishes the Insurance Examination Account and instead requires money paid for insurers for financial examinations to be deposited in the Fund for Insurance Administration and Enforcement. Current law requires dental service plans and others to pay an initial fee of $1,300 and an annual fee of $1,300. The bill would reduce the initial fee to $1,000 and the annual fee to be “determined by the Commissioner.” Carriers offering in Nevada should review the bill for further implications to their business.


NV SB 137Enacted: As originally drafted, SB 137 would have prohibited the Exchange from allowing for sale any Qualified Health Plan (QHP) that embeds the pediatric essential benefits. This section was eventually removed in Committee upon advice from Exchange officials who testified that the ACA allows medical carriers to offer embedded and non-embedded QHPs. The Committee also thoroughly discussed the primary purpose of the bill, which is to address Coordination of Benefits (COB) issues arising from dental benefits covered by a standalone dental plan (SADP) and a QHP. The final text requires dental plans to provide primary coverage for claims provided by an oral/maxillofacial surgeon which could be covered by the patient’s health and dental plan. Issuers will be prohibited from denying claims on the basis that another insurer has liability.


NV SB 159Enacted: Existing law requires every policy of health insurance, policy of group or blanket health insurance, contract for hospital or medical services and evidence of coverage to include a procedure for the arbitration of disputes related to an independent medical evaluation (IME) of a treating physician’s or chiropractor’s diagnosis and care of a patient. (NRS 689A.0403, 689B.270, 695B.182, 695C.265) This bill requires such policies, contracts and evidence to include such a procedure for dental care provided by a dentist. The GRW discussed this bill and concluded the impact to dental plans is likely minimal as IMEs are generally at the request of insurance carriers and generally rely on patient records instead of IMEs.


NV SB 341Enacted: SB 341 regulates the leasing of dental networks and includes requirements on provider notices. Amendments made during the session limit the requirements to medical discount plans that lease dental networks.




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