Dental coverage: noncovered benefits.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care, and makes a willful violation of its provisions a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires contracts between plans or insurers and providers to be fair and reasonable and requires plans and insurers to reimburse a claim for covered services within a specified period of time of receiving the claim. This bill would, with respect to a contract between a health care service plan, specialized health care service plan, or insurer covering dental services and a dentist to provide dental services to enrollees or insureds, prohibit the contract from requiring a dentist to accept an amount set by the plan or insurer as payment for dental care services provided to an enrollee or insured that are not covered services under the enrollee's contract or the insured's policy. The bill would also prohibit a provider from charging more than his or her usual and customary rate for dental services not covered under a health care service plan contract or health insurance policy. The bill would require the evidence of coverage and disclosure form for a plan contract or health insurance policy covering dental services that is issued, amended, or renewed on or after July 1, 2011, to contain a specified statement regarding noncovered services. Because a willful violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.