Section 21.42.392. Requirements relating to dental care coverage provisions.

   (a) A health care insurer who provides coverage for dental care may not include in the health care insurance plan or contract a provision that
        (1) prohibits a covered person from obtaining dental care services from a dentist of the person's choice, including a specialist;
        (2) restricts a covered person's right to receive full information from the person's dentist regarding the care or treatment options that the dentist believes are in the best interests of the person.
   (b) A health care insurance plan or contract that provides coverage for dental services that allows the health care insurer to review a treatment plan or conduct a utilization review must contain a provision that a treatment plan review or utilization review relating to dental care for a covered person receiving treatment in this state must be conducted by a dentist if the claim for reimbursement or payment is denied.
   (c) A health care insurer that provides coverage for dental care
        (1) may reimburse a covered person at a different rate because of the person's choice of a dentist if the dentist is not a part of the covered person's dental network or preferred provider organization agreement; the covered expense for non-network providers may not be less than that allowed to a network provider, although the covered expense may be reimbursed at a lower percentage or with higher deductibles than if the service had been provided within the network;
        (2) may not limit a fee set by a dentist for a service unless the service is covered under the insurer's plan or contract; and
        (3) may offer a dentist the option of entering into a preferred provider contract with the insurer that provides a fee schedule for covered services only or a fee schedule for both covered and uncovered services; under this paragraph,
             (A) the health care insurer may not
                  (i) take an action against the dentist based on the dentist's refusal to enter into a contract with an insurer;
                  (ii) fail to list a dentist who does not enter into a contract with an insurer in the insurer's marketing materials; or
                  (iii) take action against the dentist during the management or administration of a contract based on the dentist's choice of contract;
             (B) the terms or provisions of the contract
                  (i) may not violate AS 45.50.562 - 45.50.566; and
                  (ii) may authorize the insurer to provide information to the insured describing the dentist's choice of contract and fee schedules;
             (C) "covered service" means a health care service for which a health care insurer pays a benefit for all or part of the service, including a benefit that is available but limited by deductible, coinsurance, or frequency terms under the contract between the insurer and the insured.
   (d) A health care insurer may not deny
        (1) dental coverage, cancel a health care insurance plan or contract, or otherwise take action against a covered person or a dentist because the person has asserted a right described in this section;
        (2) dental coverage or eligibility for dental coverage because the covered person chooses a dentist outside of a preferred provider organization agreement.
   (e) A covered person may bring a civil action against a health care insurer to enforce the person's rights under this section if the covered person has exhausted the administrative appeal process.
   (f) A dentist who treats a covered person may not waive uncovered dental expenses for which the covered person has liability because a covered person chose the dentist outside of a dental network or a preferred provider organization agreement.
   (g) In this section,
        (1) "covered expense" means charges that are payable under plan provisions;
        (2) "dentist" means a person licensed to practice dentistry;
        (3) "preferred provider" means a dental provider who has signed an agreement with a dental care plan to provide services to plan participants at a specific rate.

Notes

History

(Sec. 1 ch 69 SLA 2000; am Sec. 3 ch 55 SLA 2009; am Sec. 1 ch 75 SLA 2010)