HR 1809
112th CONGRESS
1st Session
H. R. 1809
To amend the Employee Retirement Income Security Act of 1974 to ensure
health care coverage value and transparency for dental benefits under group
health plans.
IN THE HOUSE OF REPRESENTATIVES
May 10, 2011
Mr. ANDREWS (for himself, Mr. YOUNG of Alaska, and Mr. GOSAR) introduced
the following bill; which was referred to the Committee on Education and the
Workforce
A BILL
To amend the Employee Retirement Income Security Act of 1974 to ensure
health care coverage value and transparency for dental benefits under group
health plans.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Dental Coverage Value and Transparency Act of
2011'.
SEC. 2. VALUE AND TRANSPARENCY REQUIREMENTS FOR DENTAL BENEFITS.
(a) In General- Subpart B of part 7 of subtitle A of title I of the Employee
Retirement Income Security Act of 1974 is amended by adding at the end the
following new section:
`SEC. 716. VALUE AND TRANSPARENCY REQUIREMENTS FOR DENTAL BENEFITS.
`(a) In General- The requirements of this section shall apply to group health
plans insofar as they provide dental benefits (including, notwithstanding
section 732(c)(1), limited scope dental benefits (described in section 733(c)(2))),
directly, through health insurance coverage, or otherwise.
`(b) Value- In order to ensure that participants and beneficiaries in a group
health plan receive full value from dental benefits, the plan shall meet the
following requirements:
`(1) UNIFORM COORDINATION OF BENEFITS- The plan shall provide for coordination
of benefits in a manner so that the plan pays the same amount regardless
of other coverage for such benefits so long as the total amount paid does
not exceed 100 percent of the amount of the applicable claim. Such coordination
shall be effected consistent with such rules as the Secretary establishes,
based upon similar model regulations developed by the National Association
of Insurance commissioners.
`(2) EQUITY FOR OUT-OF-NETWORK PROVIDERS THROUGH ASSIGNMENT OF BENEFITS
AND COMPARABLE PAYMENTS- In the case of a plan that provides dental benefits
through a network of providers, the plan shall--
`(A) permit a participant or beneficiary to designate payment of dental
benefits to a provider who is not participating in the network;
`(B) provide the same dollar amount of coverage for a given procedure
regardless of whether the provider of the procedure is participating in
the network; and
`(C) not permit the application of the plan's or network's fee schedule
to services for which no benefits or reimbursement are provided.
`(c) Transparency- In order to ensure transparency in the provision of dental
benefits to participants and beneficiaries in a group health plan, the plan
shall meet the following requirements:
`(1) PROHIBITION OF BUNDLING AND DOWN CODING- The plan shall not--
`(A) systematically combine distinct dental procedures codes in a manner
that results in a reduced benefit under the plan; or
`(B) provide for a change in the benefit code to a less complex (or lower
cost) procedure than was reported if such actions are inconsistent with
the current dental terminology (CDT) or, for a provider participating
in a network, inconsistent with the terms of the network participation
agreement.
`(2) FAIR PAYMENT TERMS- The plan shall--
`(A) provide for payment of interest (at a rate specified by the Secretary)
or other penalty for clean claims paid more than 30 days after the date
of their submission;
`(B) not seek collection of overpayments more than 90 days after the date
of the overpayment; and
`(C) not recover overpayments for a dental procedure by withholding payments
for unrelated procedures.
`(3) TRANSPARENCY IN USE OF LEASE NETWORKS- A plan may use a network that
is leased by a health insurance issuer or other entity to another such issuer
or entity (where such leasing is permitted by the contract between a provider
and the issuer or other entity) only if the contract language describes
in a manner understandable to the average dental provider the terms of such
leasing,'.
(b) Conforming Amendment- The table of contents of such Act is amended by
inserting after the item relating to section 715 the following new item:
`Sec. 716. Value and transparency requirements for dental benefits.'.
(c) Effective Date- The amendments made by this section shall apply to plan
years beginning more than 1 year after the date of the enactment of this Act.
END
