BILL NUMBER: AB 2275	ENROLLED
	BILL TEXT

	PASSED THE SENATE  AUGUST 18, 2010
	PASSED THE ASSEMBLY  AUGUST 26, 2010
	AMENDED IN SENATE  AUGUST 17, 2010
	AMENDED IN SENATE  AUGUST 10, 2010
	AMENDED IN SENATE  JULY 15, 2010
	AMENDED IN SENATE  JUNE 10, 2010

INTRODUCED BY   Assembly Member Hayashi
   (Coauthors: Assembly Members Fletcher and Ma)
   (Coauthor: Senator Aanestad)

                        FEBRUARY 18, 2010

   An act to add Section 1374.195 to the Health and Safety Code, and
to add Section 10120.3 to the Insurance Code, relating to health care
coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 2275, Hayashi. Dental coverage: noncovered benefits.
   Existing law, the Knox-Keene Health Care Service Plan Act of 1975,
provides for the licensure and regulation of health care service
plans by the Department of Managed Health Care, and makes a willful
violation of its provisions a crime. Existing law also provides for
the regulation of health insurers by the Department of Insurance.
Existing law requires contracts between plans or insurers and
providers to be fair and reasonable and requires plans and insurers
to reimburse a claim for covered services within a specified period
of time of receiving the claim.
   This bill would, with respect to a contract between a health care
service plan, specialized health care service plan, or insurer
covering dental services and a dentist to provide dental services to
enrollees or insureds, prohibit the contract from requiring a dentist
to accept an amount set by the plan or insurer as payment for dental
care services provided to an enrollee or insured that are not
covered services under the enrollee's contract or the insured's
policy. The bill would also prohibit a provider from charging more
than his or her usual and customary rate for dental services not
covered under a health care service plan contract or health insurance
policy. The bill would require the evidence of coverage and
disclosure form for a plan contract or health insurance policy
covering dental services that is issued, amended, or renewed on or
after July 1, 2011, to contain a specified statement regarding
noncovered services.
   Because a willful violation of these requirements by a health care
service plan would be a crime, the bill would impose a
state-mandated local program.
   The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
   This bill would provide that no reimbursement is required by this
act for a specified reason.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1374.195 is added to the Health and Safety
Code, to read:
   1374.195.  (a)  With respect to a contract between a health care
service plan or specialized health care service plan and a dentist to
provide covered dental services to enrollees of the plan, the
contract shall not require a dentist to accept an amount set by the
plan as payment for dental care services provided to an enrollee that
are not covered services under the enrollee's plan contract. This
subdivision shall only apply to provider contracts issued, amended,
or renewed on or after January 1, 2011.
   (b) A provider shall not charge more for dental services that are
not covered services under a plan contract than his or her usual and
customary rate for those services. The department shall not be
required to enforce this subdivision.
   (c) The evidence of coverage and disclosure form, or combined
evidence of coverage and disclosure form, for every health care
service plan contract covering dental services, or specialized health
care service plan contract covering dental services, that is issued,
amended, or renewed on or after July 1, 2011, shall include the
following statement:


   IMPORTANT: If you opt to receive dental services that are not
covered services under this plan, a participating dental provider may
charge you his or her usual and customary rate for those services.
Prior to providing a patient with dental services that are not a
covered benefit, the dentist should provide to the patient a
treatment plan that includes each anticipated service to be provided
and the estimated cost of each service. If you would like more
information about dental coverage options, you may call member
services at [insert appropriate telephone number] or your insurance
broker. To fully understand your coverage, you may wish to carefully
review this evidence of coverage document.


   (d) For purposes of this section, "covered services" or "covered
dental services" means dental care services for which the plan is
obligated to pay pursuant to an enrollee's plan contract, or for
which the plan would be obligated to pay pursuant to an enrollee's
plan contract but for the application of contractual limitations such
as deductibles, copayments, coinsurance, waiting periods, annual or
lifetime maximums, frequency limitations, or alternative benefit
payments.
  SEC. 2.  Section 10120.3 is added to the Insurance Code, to read:
   10120.3.  (a) With respect to a contract between an insurer
covering dental services and a dentist to provide covered dental
services to insureds, the contract shall not require a dentist to
accept an amount set by the insurer as payment for dental care
services provided to an insured that are not covered services under
the insured's policy. This subdivision shall only apply to provider
contracts issued, amended, or renewed on or after January 1, 2011.
   (b) A provider shall not charge more for dental services that are
not covered services under a health insurance policy than his or her
usual and customary rate for those services. The department shall not
be required to enforce this subdivision.
   (c) The evidence of coverage and disclosure form, or combined
evidence of coverage and disclosure form, for every health insurance
policy covering dental services, or specialized health insurance
policy covering dental services, that is issued, amended, or renewed
on or after July 1, 2011, shall include the following statement:


   IMPORTANT: If you opt to receive dental services that are not
covered services under this policy, a participating dental provider
may charge you his or her usual and customary rate for those
services. Prior to providing a patient with dental services that are
not a covered benefit, the dentist should provide to the patient a
treatment plan that includes each anticipated service to be provided
and the estimated cost of each service. If you would like more
information about dental coverage options, you may call member
services at [insert appropriate telephone number] or your insurance
broker. To fully understand your coverage, you may wish to carefully
review this evidence of coverage document.


   (d) For purposes of this section, "covered services" or "covered
dental services" means dental care services for which the insurer is
obligated to pay, pursuant to an insured's policy, or for which the
insurer would be obligated to pay pursuant to an insured's policy but
for the application of contractual limitations such as deductibles,
copayments, coinsurance, waiting periods, annual or lifetime
maximums, frequency limitations, or alternative benefit payments.
  SEC. 3.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.