Dental coverage: noncontracting providers: assignment of 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 the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law authorizes licensed nonphysician providers that contract with a medical group, physician, or independent practice association to provide services to health care service plan enrollees to directly bill the plan for services rendered under certain circumstances. Existing law requires group health care service plans to authorize and permit assignment of a Medi-Cal beneficiary's right to reimbursement for covered services to the State Department of Health Care Services, except as specified. Existing law provides for the direct payment of group insurance medical benefits by a health insurer to the person or persons furnishing or paying for hospitalization or medical or surgical aid, as specified. This bill would require a health care service plan or health insurer that pays a contracting dental provider directly for covered services rendered to an enrollee or insured to also pay a noncontracting dental provider directly for covered services rendered to an enrollee or insured where the provider submits a written assignment of benefits signed by the enrollee or insured or the legal representative thereof, as specified. The bill would specify that a plan or insurer's payment pursuant to this provision discharges the plan or insurer's obligation with respect to the amount paid. The bill would also require a noncontracting dental provider to disclose to the enrollee or insured or the legal representative thereof that the provider is a noncontracting provider prior to accepting an assignment of benefits, and to provide additional specified written notices to the enrollee or insured or the legal representative thereof, including a written notice of the estimated full cost of the planned treatment and the estimated amount of those costs payable by the enrollee or insured. The bill would also prohibit a provider from collecting from an enrollee or insured any amount over the enrollee's or insured's estimated cost, and would require the provider to refund any overpayment to the enrollee or insured. Because a willful violation of the bill's requirements with respect to health care service plans 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.