HB1263: Dentists and oral surgeons; reimbursement for certain services.


HOUSE BILL NO. 1263
AMENDMENT IN THE NATURE OF A SUBSTITUTE
(Proposed by the House Committee on Commerce and Labor
on February 2, 2010)
(Patron Prior to Substitute--Delegate Ware, R.L.)
A BILL to amend and reenact ?? 38.2-4214, 38.2-4319, and 38.2-4509 of the Code of Virginia and to amend the Code of Virginia by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered 38.2-3407.17, relating to limitations by a dental plan on reimbursements for certain services provided by dentists and oral surgeons.

Be it enacted by the General Assembly of Virginia:

1. That ?? 38.2-4214, 38.2-4319, and 38.2-4509 of the Code of Virginia are amended and reenacted and that the Code of Virginia is amended by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered 38.2-3407.17, as follows:

? 38.2-3407.17. Payment for services by dentists and oral surgeons.

A. As used in this section:

"Covered services" means the health care services for which benefits under a policy, contract, or evidence of coverage are payable by a dental plan, including services paid by the insureds, subscribers, or enrollees because the annual or periodic payment maximum established by the dental plan has been met.

"Dental plan" includes (i) an insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis, (ii) an entity providing individual or group accident and sickness subscription contracts, (iii) a dental services plan offering or administering prepaid dental services, (iv) a health maintenance organization providing a health care plan, and (v) a dental plan organization.

B. No contract between a dental plan and a dentist or oral surgeon may establish the fee or rate that the dentist or oral surgeon is required to accept for the provision of health care services, or require that a dentist or oral surgeon accept the reimbursement paid as payment in full, unless the services are covered services under the applicable dental plan.

C. This section shall apply with respect to any contract between a dental plan and a dentist or oral surgeon for the provision of health care to patients that is entered into, amended, extended, or renewed on or after July 1, 2010.

D. The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.

? 38.2-4214. Application of certain provisions of law.

No provision of this title except this chapter and, insofar as they are not inconsistent with this chapter, ?? 38.2-200, 38.2-203, 38.2-209 through 38.2-213, 38.2-218 through 38.2-225, 38.2-230, 38.2-232, 38.2-305, 38.2-316, 38.2-322, 38.2-400, 38.2-402 through 38.2-413, 38.2-500 through 38.2-515, 38.2-600 through 38.2-620, 38.2-700 through 38.2-705, 38.2-900 through 38.2-904, 38.2-1017, 38.2-1018, 38.2-1038, 38.2-1040 through 38.2-1044, Articles 1 (? 38.2-1300 et seq.) and 2 (? 38.2-1306.2 et seq.) of Chapter 13, ?? 38.2-1312, 38.2-1314, 38.2-1315.1, 38.2-1317 through 38.2-1328, 38.2-1334, 38.2-1340, 38.2-1400 through 38.2-1444, 38.2-1800 through 38.2-1836, 38.2-3400, 38.2-3401, 38.2-3404, 38.2-3405, 38.2-3405.1, 38.2-3406.1, 38.2-3406.2, 38.2-3407.1 through 38.2-3407.6:1, 38.2-3407.9 through 38.2-3407.16 38.2-3407.17, 38.2-3409, 38.2-3411 through 38.2-3419.1, 38.2-3430.1 through 38.2-3437, 38.2-3501, 38.2-3502, subdivision 13 of ? 38.2-3503, subdivision 8 of ? 38.2-3504, ?? 38.2-3514.1, 38.2-3514.2, ?? 38.2-3516 through 38.2-3520 as they apply to Medicare supplement policies, ?? 38.2-3522.1 through 38.2-3523.4, 38.2-3525, 38.2-3540.1, 38.2-3541, 38.2-3541.1, 38.2-3542, 38.2-3543.2, Article 5 (? 38.2-3551 et seq.) of Chapter 35, ?? 38.2-3600 through 38.2-3607, Chapter 52 (? 38.2-5200 et seq.), Chapter 55 (? 38.2-5500 et seq.), Chapter 58 (? 38.2-5800 et seq.) and ? 38.2-5903 of this title shall apply to the operation of a plan.

? 38.2-4319. Statutory construction and relationship to other laws.

A. No provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, ?? 38.2-100, 38.2-136, 38.2-200, 38.2-203, 38.2-209 through 38.2-213, 38.2-216, 38.2-218 through 38.2-225, 38.2-229, 38.2-232, 38.2-305, 38.2-316, 38.2-322, 38.2-400, 38.2-402 through 38.2-413, 38.2-500 through 38.2-515, 38.2-600 through 38.2-620, Chapter 9 (? 38.2-900 et seq.), ?? 38.2-1016.1 through 38.2-1023, 38.2-1057, Article 2 (? 38.2-1306.2 et seq.), ? 38.2-1306.1, ? 38.2-1315.1, Articles 3.1 (? 38.2-1316.1 et seq.), 4 (? 38.2-1317 et seq.) and 5 (? 38.2-1322 et seq.) of Chapter 13, Articles 1 (? 38.2-1400 et seq.) and 2 (? 38.2-1412 et seq.) of Chapter 14, ?? 38.2-1800 through 38.2-1836, 38.2-3401, 38.2-3405, 38.2-3405.1, 38.2-3407.2 through 38.2-3407.6:1, 38.2-3407.9 through 38.2-3407.16 38.2-3407.17, 38.2-3411.2, 38.2-3411.3, 38.2-3411.4, 38.2-3412.1:01, 38.2-3414.1, 38.2-3418.1 through 38.2-3418.15, 38.2-3419.1, 38.2-3430.1 through 38.2-3437, 38.2-3500, subdivision 13 of ? 38.2-3503, subdivision 8 of ? 38.2-3504, ?? 38.2-3514.1, 38.2-3514.2, 38.2-3522.1 through 38.2-3523.4, 38.2-3525, 38.2-3540.1, 38.2-3541.1, 38.2-3542, 38.2-3543.2, Article 5 (? 38.2-3551 et seq.) of Chapter 35, Chapter 52 (? 38.2-5200 et seq.), Chapter 55 (? 38.2-5500 et seq.), Chapter 58 (? 38.2-5800 et seq.) and ? 38.2-5903 of this title shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (? 38.2-4200 et seq.) of this title except with respect to the activities of its health maintenance organization.

B. For plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, no provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, ?? 38.2-100, 38.2-136, 38.2-200, 38.2-203, 38.2-209 through 38.2-213, 38.2-216, 38.2-218 through 38.2-225, 38.2-229, 38.2-232, 38.2-322, 38.2-400, 38.2-402 through 38.2-413, 38.2-500 through 38.2-515, 38.2-600 through 38.2-620, Chapter 9 (? 38.2-900 et seq.), ?? 38.2-1016.1 through 38.2-1023, 38.2-1057, ? 38.2-1306.1, Article 2 (? 38.2-1306.2 et seq.), ? 38.2-1315.1, Articles 3.1 (? 38.2-1316.1 et seq.), 4 (? 38.2-1317 et seq.) and 5 (? 38.2-1322 et seq.) of Chapter 13, Articles 1 (? 38.2-1400 et seq.) and 2 (? 38.2-1412 et seq.) of Chapter 14, ?? 38.2-3401, 38.2-3405, 38.2-3407.2 through 38.2-3407.5, 38.2-3407.6 and 38.2-3407.6:1, 38.2-3407.9, 38.2-3407.9:01, and 38.2-3407.9:02, subdivisions 1, 2, and 3 of subsection F of ? 38.2-3407.10, 38.2-3407.11, 38.2-3407.11:3, 38.2-3407.13, 38.2-3407.13:1, and 38.2-3407.14, 38.2-3411.2, 38.2-3418.1, 38.2-3418.2, 38.2-3419.1, 38.2-3430.1 through 38.2-3437, 38.2-3500, subdivision 13 of ? 38.2-3503, subdivision 8 of ? 38.2-3504, ?? 38.2-3514.1, 38.2-3514.2, 38.2-3522.1 through 38.2-3523.4, 38.2-3525, 38.2-3540.1, 38.2-3542, 38.2-3543.2, Chapter 52 (? 38.2-5200 et seq.), Chapter 55 (? 38.2-5500 et seq.), Chapter 58 (? 38.2-5800 et seq.) and ? 38.2-5903 shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (? 38.2-4200 et seq.) of this title except with respect to the activities of its health maintenance organization.

C. Solicitation of enrollees by a licensed health maintenance organization or by its representatives shall not be construed to violate any provisions of law relating to solicitation or advertising by health professionals.

D. A licensed health maintenance organization shall not be deemed to be engaged in the unlawful practice of medicine. All health care providers associated with a health maintenance organization shall be subject to all provisions of law.

E. Notwithstanding the definition of an eligible employee as set forth in ? 38.2-3431, a health maintenance organization providing health care plans pursuant to ? 38.2-3431 shall not be required to offer coverage to or accept applications from an employee who does not reside within the health maintenance organization's service area.

F. For purposes of applying this section, "insurer" when used in a section cited in subsections A and B of this section shall be construed to mean and include "health maintenance organizations" unless the section cited clearly applies to health maintenance organizations without such construction.

? 38.2-4509. Application of certain laws.

A. No provision of this title except this chapter and, insofar as they are not inconsistent with this chapter, ?? 38.2-200, 38.2-203, 38.2-209 through 38.2-213, 38.2-218 through 38.2-225, 38.2-229, 38.2-316, 38.2-400, 38.2-402 through 38.2-413, 38.2-500 through 38.2-515, 38.2-600 through 38.2-620, 38.2-900 through 38.2-904, 38.2-1038, 38.2-1040 through 38.2-1044, Articles 1 (? 38.2-1300 et seq.) and 2 (? 38.2-1306.2 et seq.) of Chapter 13, ?? 38.2-1312, 38.2-1314, 38.2-1315.1, Article 4 (? 38.2-1317 et seq.) of Chapter 13, ?? 38.2-1400 through 38.2-1444, 38.2-1800 through 38.2-1836, 38.2-3401, 38.2-3404, 38.2-3405, 38.2-3407.10, 38.2-3407.13, 38.2-3407.14, 38.2-3407.15, 38.2-3407.17, 38.2-3415, 38.2-3541, Article 5 (? 38.2-3551 et seq.) of Chapter 35, ?? 38.2-3600 through 38.2-3603, Chapter 55 (? 38.2-5500 et seq.), Chapter 58 (? 38.2-5800 et seq.) and ? 38.2-5903 of this title shall apply to the operation of a plan.

B. The provisions of subsection A of ? 38.2-322 shall apply to an optometric services plan. The provisions of subsection C of ? 38.2-322 shall apply to a dental services plan.

C. The provisions of Article 1.2 (? 32.1-137.7 et seq.) of Chapter 5 of Title 32.1 shall not apply to either an optometric or dental services plan.

HOUSE BILL NO. 1263
Offered January 19, 2010
A BILL to amend the Code of Virginia by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered 38.2-3407.17, relating to limitations by a dental plan on reimbursements for certain services provided by dentists and oral surgeons.
Patron-- Ware, R.L.

Committee Referral Pending

Be it enacted by the General Assembly of Virginia:

1.  That the Code of Virginia is amended by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered 38.2-3407.17 as follows:

? 38.2-3407.17. Payment for services by dentists and oral surgeons.

A. As used in this section:

"Covered services" means the health care services that a dentist or oral surgeon has agreed to provide on behalf of a dental plan to its insured, subscribers, or enrollees with an expectation of receiving payment, other than copayments or deductibles, directly or indirectly from the dental plan.

"Dental plan" includes (i) an insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical, and surgical or major medical coverage on an expense-incurred basis, (ii) an entity providing individual or group accident and sickness subscription contracts, (iii) a dental services plan offering or administering prepaid dental services, (iv) a health maintenance organization providing a health care plan, and (v) a dental plan organization.

B. No contract between a dental plan and a dentist or oral surgeon for the provision of health care to patients may establish the fee or rate that the dentist or oral surgeon is required to accept for the provision of health care services or require that a dentist or oral surgeon accept the reimbursement paid by the dental plan as payment in full for health care services unless the services are covered services under the applicable dental plan.

C. This section shall apply with respect to any contract between a dental plan and a dentist or oral surgeon for the provision of health care to patients that is entered into, amended, extended, or renewed on or after July 1, 2010.