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 dental benefit plans’ unreasonable or unjustified 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 upon several successful pieces of legislation sponsored by CDA 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 the benefits are immediately experienced by dentists and their patients, and other times the benefits are delayed because, for example, the law’s full implementation is delayed. Either way, CDA will continue pushing for reforms that require plans to provide more meaningful coverage and be more transparent with their contracts and communications.”
Here is a look at what 10 CDA-sponsored bills signed into law over the last 15 years have accomplished for California dentists and their patients.
1. Consumer protections and rate review
This year’s AB 1048 solves some of the key disparities between dental benefit plans and medical insurance with respect to consumer protections and regulatory oversight. Signed into law in September and taking effect in January 2025, this legislation will:
- Prohibit plans from denying claims related to a patient’s preexisting dental conditions.
- Prohibit plans in the large group market from imposing waiting periods before patients can access their full benefits.
- Require state regulatory review of the premiums charged by dental plans to help protect consumers from unreasonable or unjustified rates.
Learn more about the bill in the CDA article.
2. Plans must disclose whether state or federally regulated
Also signed into law this year, AB 952 will require dental plans to clearly disclose at the time of coverage determination whether a patient’s plan is state or federally regulated.
This disclosure matters because an estimated 40% of Californians are enrolled in self-insured plans that are exempt from California’s laws and instead are regulated under the federal Employee Retirement Income Security Act (ERISA). Confusion about a patient’s coverage therefore often results and persists until the billing process is completed and the dental plan has denied coverage or cited a billing exemption for services already rendered.
CDA-sponsored AB 952 requires dental plans to disclose through their online patient portal or upon a dental office’s request whether the patient’s plan is state regulated. As part of this disclosure, the plan must also include the phrase “state regulated” on the patient’s electronic or physical insurance identification card. The improved disclosure will additionally be helpful when a conflict occurs with a plan by making it easier to identify which regulatory entity to contact. The bill takes effect in January 2025.
Learn how this year’s two bills became law through CDA’s innovative advocacy campaign.
3. Required reimbursements for dentists’ increased PPE costs
CDA-sponsored legislation that took effect in January 2022 requires insurance plans, including dental benefit plans, to reimburse health care providers for increased costs of PPE during future public health emergencies.
CDA spearheaded the bill when the COVID-19 pandemic shone a light on health care service plans’ ability to make record profits while paying fewer claims due to fewer patients receiving care.
During future public health emergencies, the law requires health care service plans to reimburse California-licensed dentists, physicians and other specified health care providers for critical PPE and other business expenses needed to prevent the spread of respiratory-transmitted infectious diseases.
Past CDA Government Affairs Council Chair Stephanie Sandretti, DDS, said after the bill’s signing: “Requiring insurance plans to provide timely financial assistance for PPE and other increased business expenses will help ensure that provider networks remain intact and prevent future disruptions in access to care.”
4. Dental benefit plan transparency during ‘network leasing’
Insufficient transparency in network leasing by 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 a successful CDA-sponsored bill, dental benefit plans that lease access to another plan’s network of contracted dentists are required to take specific steps, including:
- Clearly identify a contract clause allowing network leasing.
- Maintain an up-to-date website list of all third parties that have access to a provider network contract.
- Give dentists the ability to opt out of network leasing.
Learn more about AB 954, which took effect for any contracts entered into as of Jan. 1, 2020.
5. Uniform disclosure of dental benefits required
As of Jan. 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 the one used by medical plans and provides beneficiaries with a summary of plan details, including covered services, reimbursement levels, estimated enrollee cost share, limitations and exceptions. The law holds plans accountable to comparable standards as medical plans.
“As providers, we all too often see patients in our offices struggle to understand what procedures are and are not covered,” said past CDA President Natasha Lee, DDS, in a news release after the bill’s signing. “We aim to stop that and ensure patients get the care they need with SB 1008.”
6. Medical loss ratio reporting helps patients understand dental plans’ value
CDA-sponsored legislation signed into law in 2014 requires dental benefit plans to file an annual Medical Loss Ratio report to inform Californians about the value of their dental insurance plans.
A plan’s medical loss ratio indicates how much 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 revenue. This reporting requirement has provided consumers, CDA and policymakers with nine years of data and insight into the dental insurance market in California.
This first-in-the-nation dental MLR reporting bill kicked off a national dialogue about dental MLR and the value of dental plans with five other states passing dental MLR reporting legislation since that time. Massachusetts’ dental MLR requirement will take effect in 2024.
7. Plans must notify contracted dentists of changes to coverage, fees
Dental benefit plans are required under CDA-sponsored AB 2252 signed into law in 2012 to notify contracted dentists (1) when the coverage of a plan the dentist is in network for changes, (2) when the fee schedule changes or there is a change in how treatment is reimbursed and (3) when a claim adjudication system conversion may delay claims processing and payments.
8. Plans prohibited from capping fees for noncovered procedures
CDA sponsored AB 2275 in 2010 because it understood that dental benefit plans were beginning to dictate fees for procedures that the policy did not cover. AB 2275, which took effect in January 2011, prohibits plans from capping fees charged for procedures that a plan doesn’t cover and never pays for. The outcome of this successful bill is that dentists are allowed to charge patients their usual fee for noncovered services, which are the fees that a dental practice would charge a patient who has no coverage. CDA members can learn more by logging in to read Is it a Covered benefit? Understanding the Noncovered Services Law.
9. Improved coordination of benefits
A bill sponsored by CDA that took effect in 2009 established payment responsibility for dental benefit plans that are secondary for a patient with dual coverage.
AB 895 (1) prohibits “nonduplication of benefit policies,” (2) requires dental benefit plans to declare their coordination of benefits policy prominently in their evidence of coverage documents or in its contracts or policies with both enrollees and insureds and (3) requires the primary dental benefit plan that is coordinating dental benefits with one or more other plans or insurers to pay the maximum amount required by its contract and the secondary dental benefit plan to pay the lesser of either the amount that it would have paid in the absence of any other dental benefit coverage or the insured’s total out-of-pocket cost payable as defined in the bill.
10. Refund demand requirements
Taking effect in 2009, CDA-sponsored legislation clarified requirements related to plans that seek to recover dental practices’ alleged overpayments. SB 1387 gives the provider 30 working days to respond to a refund demand by either paying the refund or by formally appealing the refund demand.
Watch for news about what’s on CDA’s 2024 dental plan reform advocacy agenda, as well as updates on AB 1048 and AB 952 as their effective date nears.
Visit CDA’s Dental Plan Action Center for all the news and resources related to CDA’s pursuit of dental plan reform along with resources to help members conduct business with dental plans now.