Dental plan reform continues to lead CDA’s advocacy agenda. Two CDA-sponsored bills signed into law last month by Gov. Gavin Newsom are the latest legislative outcomes to benefit California dentists and their patients. AB 1048 and AB 952 will, among other things, help protect consumers from unreasonable or unjustified dental benefit plan rates and prohibit plans in the large group market from imposing arbitrary waiting periods before patients can access their full benefits. The two bills will become law in January 2025.
But this year’s successful reform efforts follow and build on several successful pieces of legislation CDA has sponsored in recent years as part of a multi-year, multi-pronged strategy that also includes legal action.
“We are in this fight for the long haul,” said CDA President John Blake, DDS. “Dental plan reform takes time.” Sometimes dentists and their patients experience benefits immediately, and other times benefits are delayed because, for example, the full implementation of the law is delayed. In any case, CDA will continue to push for reforms that require plans to provide more meaningful coverage and be more transparent with their contracts and communications.
Here’s a look at what 10 CDA-sponsored bills signed into law in the past 15 years have accomplished for California dentists and their patients.
1. Consumer protection and rate review
This year’s AB 1048 addresses some of the key disparities between dental benefit plans and health insurance in terms of consumer protection and regulatory oversight. Signed in September and taking effect in January 2025, this law will:
- Prohibit plans from denying claims related to patients’ existing dental conditions.
- Prohibit plans in the large group market from imposing waiting periods before patients can access their full benefits.
- Demand a state regulatory review of premiums charged by dental plans to protect consumers from unreasonable or unjustified rates.
Learn more about the account in the CDA article.
2. Plans must disclose whether they are state or federally regulated
Also signed into law this year, AB 952 will require dental plans to clearly disclose at the time of determining coverage whether a patient’s plan is state or federally regulated.
This disclosure is important because an estimated 40% of Californians are enrolled in self-insured plans that are exempt from California law and are instead governed by the federal Employee Retirement Income Security Act (ERISA). Because of this, confusion about a patient’s coverage often occurs until the billing process is completed and the dental plan denies coverage or cites a waiver of payment for services already provided.
CDA-sponsored AB 952 requires dental plans to disclose through their online patient portal or at the request of a dental office whether a patient’s plan is regulated by the state. As part of this disclosure, the plan must also include the phrase “state regulated” on the patient’s electronic or physical insurance identification card. Improved disclosure will also be helpful when there are conflicts with the plan as it will make it easier to identify which regulatory body to contact. The bill will enter into force in January 2025.
Learn how this year’s two bills became law through CDA’s innovative advocacy campaign.
3. Required fees for increased costs of PPE for dentists
CDA-sponsored legislation that took effect in January 2022 requires insurance plans, including dental benefit plans, to reimburse healthcare providers for increased PPE costs during future public health emergencies.
The CDA spearheaded the bill when the COVID-19 pandemic shined a light on health plans’ ability to generate record profits while paying fewer claims due to fewer patients receiving care.
During future public health emergencies, the law requires health service plans to reimburse dentists, physicians and other designated health care professionals licensed in California for critical PPE and other business expenses needed to prevent the spread of respiratory-borne infectious diseases.
Former CDA Government Affairs Council Chair Stephanie Sandretti, DDS, said after the bill was signed, “Requiring insurance plans to provide timely financial assistance for PPE and other increased business expenses will help ensure provider networks remain intact and prevent future disruptions in access to care. “
4. Transparency of dental benefits plan during “network lease”
Insufficient transparency of network leases through dental benefit plans has long caused confusion for patients and dentists, making it difficult for providers to educate patients about treatment options and the cost of care. But under successful CDA-sponsored legislation, dental benefit plans that lease access to another plan’s network of contracted dentists must take certain steps, including:
- Clearly identify the contract clause that allows network leasing.
- Maintain an up-to-date list of all third parties who have access to the network agreement with providers.
- Give dentists the option to opt out of network leases.
Learn more about AB 954, which became effective for all contracts entered into on January 1, 2020.
5. Uniform publication of dental benefits is required
Beginning January 1, 2021, standardized disclosures are required for all dental benefit plans using a uniform summary of benefits and coverage template as a result of CDA-sponsored SB 1008 signed into law in 2018. The uniform matrix is similar to that used by medical plans and provides beneficiaries with a summary plan details, including covered services, reimbursement levels, estimated enrollee cost-sharing, limitations, and exclusions. The law holds plans accountable to comparable standards as medical plans.
“As providers, all too often we see patients in our offices struggle to understand which procedures are covered and which are not,” former CDA President Natasha Lee, DDS, said in a news release after the legislation was signed. “Our goal is to stop that and ensure patients get the care they need with SB 1008.”
6. Medical loss ratio reporting helps patients understand the value of dental plans
CDA-sponsored legislation signed into law in 2014 requires dental benefit plans to file an annual medical loss ratio report to inform Californians of the value of their dental insurance plans.
A plan’s medical loss ratio shows how many of its premium dollars are spent on patient care. AB 1962 created a standardized reporting system for dental plans to uniformly disclose how they spend premium income. This reporting requirement provided consumers, CDAs, and policymakers with nine years of data and insight into the California dental insurance market.
This first-in-the-nation MLR dental reporting bill started a national dialogue about dental MLR and the value of dental plans with five other states that have since enacted dental MLR reporting legislation. The dental MLR requirement in Massachusetts will go into effect in 2024.
7. Plans must notify contracted dentists of changes in coverage, fees
Dental benefit plans are required under CDA-sponsored AB 2252, signed into law in 2012, to notify contracted dentists (1) when the plan’s in-network dentist coverage changes, (2) when the schedule changes reimbursement or there is a change in how treatment is reimbursed and (3) when the conversion of the claims adjudication system may delay the processing of claims and payments.
8. Plans are prohibited from limiting fees for noncovered procedures
CDA sponsored AB 2275 in 2010 because it realized that dental benefit plans were beginning to dictate fees for procedures not covered by the policy. AB 2275, which took effect in January 2011, prohibits plans from limiting the fees charged for procedures that the plan does not cover and never pays for. The result of this successful bill is that dentists can charge patients their regular fee for non-covered services, which are the fees that a dental office would charge a patient who does not have coverage. CDA members can learn more by signing up to read Is it a covered benefit? Understanding the law about uncovered services.
9. Improved coordination of benefits
A CDA-sponsored bill that went into effect in 2009 established responsibility for paying dental benefit plans secondary to a patient with dual coverage.
AB 895 (1) prohibits “non-duplication of benefit policies,” (2) requires dental benefit plans to prominently post their coordination of benefit policies in their evidence of coverage documents or in their contracts or policies with both enrollees and policyholders, and (3 ) requires a primary dental benefit plan that coordinates dental benefits with one or more other plans or insurers to pay the maximum amount required by its contract and a secondary dental benefit plan to pay less than the amount it would pay in the absence of any other dental benefit coverage or the total an out-of-pocket cost to the insured as defined in the bill.
10. Requests for refunds
Taking effect in 2009, CDA-sponsored legislation clarified requirements for plans that aim to recover alleged overpayments from dental practices. SB 1387 gives a supplier 30 business days to respond to a refund request by either paying a refund or filing a formal appeal of the refund request.
Stay tuned for news on what’s on the 2024 CDA dental plan reform advocacy agenda, as well as updates on AB 1048 and AB 952 as their effective date approaches.
Visit CDA’s Dental Plan Action Center for all the news and resources related to CDA’s push for dental plan reform, along with resources to help members do business with dental plans now.
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