NCOIL Adopts Transparency In Dental Benefits Contracting Model Act

By Staff Reports

The National Council of Insurance Legislators have adopted the NCOIL Transparency in Dental Benefits Contracting Model Act at year’s end.

The model was sponsored by AR Rep. Deborah Ferguson, vice chair of the NCOIL Health Insurance & Long-Term Care Issues Committee (Health Committee), and North Dakota Rep. George Keiser, former NCOIL president. The measure passed on a voice vote by both the Health Committee and the Executive Committee.

The model was first introduced at the 2019 NCOIL Annual Meeting in Austin, Texas and contained five substantive sections, NCOIL said in a news release. After work and compromise among everyone involved, the model was narrowed to include three sections dealing with network leasing arrangements, prior authorization payments, and virtual credit cards, all under the umbrella of transparency.

Rep. Keiser said, “I am proud that I was able to introduce this Model and that Rep. Ferguson, as a dentist who deals with these issues so often, was able to guide it across the finish line. The Model protects both patients and dentists and should be considered by states during their next legislative session.”

“These issues are very important to me as I have seen how if left unchecked, the practices that the Model addresses can harm both patients and dentists,” stated Rep. Ferguson. “I am confident that this Model provides for the ultimate level of transparency. Transparency in dental insurance and dental care is of the utmost importance for the dentist, but more so for the patient, as they end up absorbing unnecessary costs.”

NY Assemblywoman Pamela Hunter, chair of the NCOIL Health Committee, remarked: “I am very pleased with all of the hard work that Rep. Keiser, Rep. Ferguson, and stakeholders put into getting this Model adopted. When discussions on the Model began, both sides were far apart on the issues, but NCOIL once again provided a forum where people with difference perspectives can work together to develop sound insurance public policy.”

During the drafting discussions of the model, NCOIL legislators and staff heard from a wide array of interested parties including the American Dental Association (ADA); the National Association of Dental Plans (NADP); America’s Health Insurance Plans (AHIP); the American Council of Life Insurers (ACLI); the Health Benefits Institute; and the American Bankers Association (ABA), the release said.

NCOIL CEO, Commissioner Tom Considine, stated, “The Model came a long way from when it was first introduced and that really is due in large part to the leadership from Rep. Keiser and Rep. Ferguson. As sponsors, they were able to guide the conversations to a point where sufficient consensus could be reached so the Model could be adopted and presented to states for consideration. Everyone had the same goal of ensuring that people have access to affordable and quality dental care, and this Model highlights the importance of that.”

Highlights of the model include requiring fair and transparent network contracts, the release said. The model permits a contracting entity to grant a third-party access to a provider network contract, or a provider’s dental services or contractual discounts provided pursuant to a provider
network contract if certain requirements are met such as:

• at the time the contract is entered into or renewed, or a when there are material modifications to a contract relevant to granting access to a provider network contract to a third party, the dental carrier allows any provider which is part of the carrier's provider network to choose to not participate in third party access to the contract or to enter into a contract directly with the health insurer that acquired the provider network;
• the third party accessing the contract agrees to comply with all of the contract's terms;
• the contracting entity identifies, in writing or electronic form to the provider, all third
parties in existence as of the date the contract is entered into or renewed; and
• the contracting entity notifies network providers that a new third party is leasing or
purchasing the network at least 30 days in advance of the relationship taking effect.

The model also prohibits dental benefit plans from denying any claim subsequently submitted by a dentist for procedures specifically included in a prior authorization unless an exception applies for each procedure denied such as:

• benefit limitations such as annual maximums and frequency limitations not applicable at the time of the prior authorization are reached due to utilization subsequent to issuance of the prior authorization;
• the documentation for the claim provided by the person submitting the claim clearly fails to support the claim as originally authorized; or
• if, subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care.

Further, the model prohibits dental benefit plans from restricting the methods of payment from the dental benefit plans or its vendor or the health maintenance organization to the dentist in which the only acceptable payment method is a credit card payment. If initiating or changing payments to a dentist using electronic funds transfer payments, including virtual credit card payments, a dental benefit plan or its contracted vendor or health maintenance organization shall:

• notify the dentist if any fees are associated with a particular payment method; and
• advise the dentist of the available methods of payment and provide clear instructions to the dentist as to how to select an alternative payment method.