Background:

Regulation of health plans.

A "health plan" is defined as any policy, contract, or agreement offered by a health carrier to provide, arrange, reimburse, or pay for health care services. Certain types of coverage are excluded from the definition of "health plan," including dental-only coverage and limited health care services offered by limited health care service contractors.

Utilization review: Carriers offering a health plan are required to maintain a documented utilization review program description and written utilization review criteria based on reasonable medical evidence. Carriers must make their clinical protocols, medical management standards, and other review criteria available to participating providers. By rule, they are prohibited from penalizing or threatening a provider or facility with a reduction in future payment or termination of participating provider or facility status because the provider or facility disputes the carrier's determination regarding coverage or payment.

Prior authorization: A carrier offering a health plan may not retrospectively deny coverage for care that had prior authorization under the plan's written policies at the time the care was rendered.

Grievances and review of adverse benefit determinations: Carriers and health plans must have comprehensive and effective processes for grievances and review of adverse benefit determinations, and the processes must be consistent with requirements in statute. For example, the statute requires that the carrier and plan provide written notice to an enrollee, his or her designated representative, and his or her provider of its decision to deny, modify, reduce, or terminate payment, coverage, or authorization for services or benefits. By rule, carriers and health plans are prohibited from taking or threatening to take punitive action against a provider acting on behalf of or in support of an enrollee as part of a review of an adverse benefit determination.

Review by independent review organizations: An enrollee in a health plan may seek review by a certified independent review organization (IRO) if: (1) a carrier denies, modifies, reduces, or terminates coverage of, or payment for, a health care service; and (2) the enrollee has exhausted the carrier's grievance process or the carrier has exceeded timelines for grievances. Reviewers for the IRO make determinations regarding the medical necessity or appropriateness of, and the application of plan provisions to, health care services for an enrollee. An IRO determination must be consistent with the plan unless it is unreasonable or inconsistent with evidence-based medical practice. Only contract specialists may make determinations about application of plan provisions and only clinical reviewers may determine medical necessity and appropriateness. An IRO is required to notify the enrollee and the carrier of the result and rationale for the determination within 15 days of receiving all necessary information or 20 days after receiving the request (or 25 days in exceptional circumstances), whichever is earlier. The carrier must timely implement the determination and pay the IRO's fees.

Explanation of Benefits.

An explanation of benefits (EOB) is a statement used by a health carrier to inform an enrollee of how the carrier reimbursed a provider for services rendered on the enrollee's behalf. An EOB may include information on the service provided, the amount charged by the provider, the amount reimbursed by the health plan, and the enrollee's responsibility. Health carriers must submit their rates and forms to the Insurance Commissioner (Commissioner) for approval. The Commissioner may disapprove of an insurance contract if:

it contains inconsistent, ambiguous, or misleading content;
the carrier is soliciting purchase of the product through deceptive advertising;
it contains unreasonable restrictions on the treatment of patients; or
the benefits are unreasonable in relation to the amount charged.

Health carriers do not submit EOBs to the Commissioner for approval.

Dental Care and Preexisting Conditions.

Under the federal Affordable Care Act (ACA), dental care for adults is not an essential health benefit, but is covered as an essential health benefit for children under 18. Under the ACA, health carriers may not deny someone a policy because they have a preexisting condition, refuse to cover services necessary to treat a preexisting condition, or charge a higher premium based on a person’s health status.

Summary of Bill:

Regulation of Dental-only plans.

A "health plan" includes a dental-only plan offered after December 31, 2019, for purposes of the statutes regulating utilization review programs, prior authorization, grievances and review of adverse benefit determinations, and review by independent review organizations.

A health carrier offering a dental-only plan may not take or threaten to take punitive action against a provider acting on behalf of or in support of a covered person because the provider disputes the carrier's determination regarding coverage or payment for a dental service.

A health carrier offering a dental-only plan may not deny a claim for a covered dental service provided by a treating dentist to a covered person. If the carrier denies such a claim, the carrier may not advertise that the carrier covers the service in promotional materials or an explanation of benefits sent to prospective or current members.

Explanation of Benefits.

Beginning October 1, 2019, a health carrier offering a dental-only plan must annually submit to the Insurance Commissioner (Commissioner) the Explanation of Benefits (EOB) form the carrier plans to use for the upcoming plan year. The submission must include a list of standard definitions and terms the carriers will use and an example of a completed form.

No later than July 1, 2020, the Commissioner must utilize the EOB forms received in 2019 to adopt rules setting minimum standards for the format, terms, and definitions for EOB forms used by dental-only plans. The rules must include a model EOB form, model terms, and model definitions. Beginning in plan year 2021, a health carrier offering a dental-only plan may not use an EOB form, or the standard definitions or terms used on the form, if the Commissioner has disapproved of the form, definitions, or terms. The Commissioner may disapprove of an EOB form, or the definitions or terms used on the form, if he or she finds the form, definitions, or terms are confusing, inconsistent, or misleading. The Commissioner may not disapprove a form, definitions, or terms that are substantially identical to the model form, definitions, and terms. The EOB requirements do not apply to fully capitated dental plans.

Preexisting conditions.

Health benefit plans, health care service contractors, or health carriers offering dental benefits may not deny or limit coverage based on an individual's oral health, including a missing tooth, at the time coverage begins.