1.1                          A bill for an act 
  1.2             relating to health; clarifying that certain disclosure 
  1.3             and consumer protection requirements apply for dental 
  1.4             services; requiring certain disclosures of dental 
  1.5             benefits; amending Minnesota Statutes 1998, sections 
  1.6             62J.70, subdivision 3; and 62Q.51, subdivision 1; 
  1.7             Minnesota Statutes 1999 Supplement, section 62Q.68, 
  1.8             subdivision 1; proposing coding for new law in 
  1.9             Minnesota Statutes, chapter 62Q.  
  1.10  BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 
  1.11     Section 1.  Minnesota Statutes 1998, section 62J.70, 
  1.12  subdivision 3, is amended to read: 
  1.13     Subd. 3.  [HEALTH PLAN COMPANY.] "Health plan company" 
  1.14  means health plan company as defined in section 62Q.01, 
  1.15  subdivision 4, and includes an insurance company licensed under 
  1.16  chapter 60A to offer, sell, or issue a policy of accident and 
  1.17  sickness insurance as defined in section 62A.01 or a nonprofit 
  1.18  health service plan corporation regulated under chapter 62C that 
  1.19  only provides dental coverage. 
  1.20     Sec. 2.  Minnesota Statutes 1998, section 62Q.51, 
  1.21  subdivision 1, is amended to read: 
  1.22     Subdivision 1.  [DEFINITION.] For purposes for this 
  1.23  section, "point-of-service option" means a health plan under 
  1.24  which the health plan company will reimburse an appropriately 
  1.25  licensed or registered provider for providing covered services 
  1.26  to an enrollee, without regard to whether the provider belongs 
  1.27  to a particular network and without regard to whether the 
  2.1   enrollee was referred to the provider by another provider.  For 
  2.2   purposes of this section, health plan company includes an 
  2.3   insurance company licensed under chapter 60A to offer, sell, or 
  2.4   issue a policy of accident and sickness insurance as defined in 
  2.5   section 62A.01 or a nonprofit health service plan corporation 
  2.6   regulated under chapter 62C that only provides dental coverage.  
  2.7      Sec. 3.  Minnesota Statutes 1999 Supplement, section 
  2.8   62Q.68, subdivision 1, is amended to read: 
  2.9      Subdivision 1.  [APPLICATION.] For purposes of sections 
  2.10  62Q.68 to 62Q.72, the terms defined in this section have the 
  2.11  meanings given them.  For purposes of sections 62Q.69 and 62Q.70 
  2.12  62Q.72, the term "health plan company" does not include includes 
  2.13  an insurance company licensed under chapter 60A to offer, sell, 
  2.14  or issue a policy of accident and sickness insurance as defined 
  2.15  in section 62A.01 or a nonprofit health service plan corporation 
  2.16  regulated under chapter 62C that only provides dental coverage 
  2.17  or vision coverage. 
  2.18                     DENTAL BENEFIT DISCLOSURE
  2.19     Sec. 4.  [62Q.75] [DEFINITIONS.] 
  2.20     Subdivision 1.  [APPLICABILITY.] For purposes of sections 
  2.21  62Q.75 to 62Q.78, the terms defined in this section have the 
  2.22  meaning given them.  
  2.23     Subd. 2.  [DENTAL CARE SERVICES.] "Dental care services" 
  2.24  means services performed by a licensed dentist or any person 
  2.25  working under the dentist's supervision as permitted under 
  2.26  chapter 150A, which an enrollee might reasonably require to 
  2.27  maintain good dental health, including at a minimum, but not 
  2.28  limited to, preventive services, diagnostic services, emergency 
  2.29  dental care, and restorative services.  
  2.30     Subd. 3.  [DENTAL PLAN.] "Dental plan" means a policy, 
  2.31  contract, or certificate offered by a dental organization for 
  2.32  the coverage of dental care services.  Dental plan means 
  2.33  individual or group coverage.  Dental plan does not include the 
  2.34  coverage of dental care services that is offered as part of a 
  2.35  health plan that provides a set of comprehensive health services 
  2.36  offered, sold, or issued by a health insurer or health 
  3.1   maintenance organization.  
  3.2      Subd. 4.  [DENTIST.] "Dentist" means a person licensed to 
  3.3   practice dentistry under chapter 150A. 
  3.4      Subd. 5.  [EMERGENCY DENTAL CARE.] "Emergency dental care" 
  3.5   means the provision of dental care services for a sudden, acute 
  3.6   dental condition that would lead a prudent layperson to 
  3.7   reasonably expect that the absence of immediate care would 
  3.8   result in serious impairment to the dentition or would place the 
  3.9   person's oral health in serious jeopardy.  
  3.10     Subd. 6.  [ENROLLEE.] "Enrollee" means an individual 
  3.11  covered by a dental organization and includes an insured, policy 
  3.12  holder, subscriber, contract holder, member, covered person, or 
  3.13  certificate holder.  
  3.14     Subd. 7.  [DENTAL ORGANIZATION.] "Dental organization" 
  3.15  means a health insurer licensed under chapter 60A; a health 
  3.16  service plan corporation licensed under chapter 62C; a health 
  3.17  maintenance organization licensed under chapter 62D; or a 
  3.18  community integrated service network licensed under chapter 62N 
  3.19  that provides, either directly or through contracts with 
  3.20  providers or other persons, dental care services or arranges for 
  3.21  the provision of these services to enrollees on the basis of a 
  3.22  fixed prepaid sum without regard to the frequency or extent of 
  3.23  services furnished to any particular enrollee.  
  3.24     Sec. 5.  [62Q.76] [TERM OF COVERAGE DISCLOSURE.] 
  3.25     Subdivision 1.  [TERMS OF COVERAGE.] A dental organization 
  3.26  must provide, upon enrollment and annually thereafter, and upon 
  3.27  request to prospective enrollees, a clear and concise 
  3.28  description of the following terms of coverage:  
  3.29     (1) the dental care services and other benefits to which 
  3.30  the enrollee is entitled under the dental plan; 
  3.31     (2) any exclusions or limitations on the services, kind of 
  3.32  services, benefits, or kinds of benefits to be provided, 
  3.33  including any deductible or copayment features and any 
  3.34  requirements for referrals to specialists, prior authorizations, 
  3.35  and second opinions; 
  3.36     (3) a description as to how services, including emergency 
  4.1   dental care and out-of-area service, may be obtained; 
  4.2      (4) the total amount of payment and copayment, if any, for 
  4.3   dental care services, which the enrollee is obligated to pay; 
  4.4      (5) a description of the dental organization's complaint 
  4.5   process, including information as to how an enrollee submits a 
  4.6   complaint and a statement identifying the commissioner with whom 
  4.7   complaints may be registered; 
  4.8      (6) a list of participating providers, including the 
  4.9   provider's address and telephone number; and 
  4.10     (7) a telephone number by which the enrollee may obtain 
  4.11  additional information regarding coverage.  
  4.12     Subd. 2.  [ENROLLEES' RIGHTS.] As part of the evidence of 
  4.13  coverage or contract, a dental organization must provide a clear 
  4.14  and complete statement of enrollees' rights.  The statement must 
  4.15  be in bold print and captioned "Enrollee Rights" and must 
  4.16  include, but not be limited to, the following language or in 
  4.17  substantially similar language approved in advance by the 
  4.18  commissioner:  
  4.19                          "ENROLLEE RIGHTS
  4.20     (1) Enrollees have the right to available and accessible 
  4.21  dental care services, including emergency services, as defined 
  4.22  in your dental plan 24 hours a day and seven days a week. 
  4.23     (2) Enrollees have the right to be informed of dental 
  4.24  health problems and to receive information regarding treatment 
  4.25  alternatives and risks, which is sufficient to assure informed 
  4.26  choice. 
  4.27     (3) Enrollees have the right to refuse treatment and the 
  4.28  right to privacy of dental and financial records maintained by 
  4.29  the dental organization and its dental providers, in accordance 
  4.30  with existing law. 
  4.31     (4) Enrollees have the right to file a grievance with the 
  4.32  dental organization and the commissioner of either commerce or 
  4.33  health and the right to initiate a legal proceeding when 
  4.34  experiencing a problem with the dental organization or its 
  4.35  dental providers." 
  4.36     Subd. 3.  [ACCESS TO DENTISTS.] (a) If a dental 
  5.1   organization restricts or limits an enrollee's access to 
  5.2   dentists, the organization must provide a clear and concise 
  5.3   description on how it selects its participating dentists, the 
  5.4   number of dentists participating in the plan, the number of 
  5.5   dentists who have applied for participation and have been 
  5.6   denied, and the policy and procedures it maintains for enrollees 
  5.7   to receive dental care from dentists outside of an 
  5.8   organization's network of participating dentists.  
  5.9      (b) If a dental organization requires enrollees to receive 
  5.10  dental care from a network of participating dentists, the 
  5.11  organization must disclose to enrollees any limitations on 
  5.12  dental care services that are provided outside of the network's 
  5.13  service area, including an increase in copayments or deductibles.
  5.14     (c) A dental organization must provide a clear and concise 
  5.15  description of its procedures for receiving care from a dental 
  5.16  specialist and any requirements for referrals for specialty care.
  5.17     Sec. 6.  [62Q.77] [DENTAL BENEFIT PLAN REQUIREMENTS.] 
  5.18     Subdivision 1.  [EMERGENCY COVERAGE.] A dental organization 
  5.19  must provide coverage for palliative treatment for emergency 
  5.20  dental care services regardless of whether the services are 
  5.21  provided by a participating dentist or an out-of-network dentist 
  5.22  provided that the enrollee has made a reasonable attempt to 
  5.23  first obtain emergency dental care service through the 
  5.24  appropriate participating dentist.  
  5.25     Subd. 2.  [CONTINUITY OF CARE.] If enrollees are required 
  5.26  to access services through a specific primary care dentist, the 
  5.27  dental organization must establish a written plan that provides 
  5.28  for continuity of care in the event of contract termination 
  5.29  between the dental organization and any of the contracted 
  5.30  primary care dentists.  The written plan must explain:  
  5.31     (1) how the dental organization will inform affected 
  5.32  enrollees about termination at least 30 days before the 
  5.33  termination is effective if the dental organization has received 
  5.34  at least 120 days' prior notice; and 
  5.35     (2) how the dental organization will inform the affected 
  5.36  enrollees about what other participating dentists are available 
  6.1   to assume care and how it will facilitate an orderly transfer of 
  6.2   its enrollees from the terminating dentist to a new dentist to 
  6.3   maintain continuity of care. 
  6.4      Subd. 3.  [UTILIZATION PROFILING.] (a) A dental 
  6.5   organization that uses utilization profiling as a method of 
  6.6   differentiating provider reimbursement, as a requirement for 
  6.7   continued participation in the organization's provider network, 
  6.8   or for varying patient copayments must base utilization profiles 
  6.9   upon the professional standards used to affect patient care 
  6.10  within their service area.  The methodology used to develop 
  6.11  utilization profiles shall be made available to enrollees and 
  6.12  participating dentists upon request.  
  6.13     (b) If a dental organization intends to modify a dentist's 
  6.14  continued participation in the organization's network or modify 
  6.15  the dentist's reimbursement rate, it must first provide written 
  6.16  notice of the modification to the affected dentist.  The notice 
  6.17  must be delivered at least 120 days before the proposed action 
  6.18  and include the specific reasons for the organization's action.  
  6.19     (c) If a dental organization conducts or uses utilization 
  6.20  profiling as a criteria for termination or treating a 
  6.21  participating dentist in any way differently than other 
  6.22  participating dentists, the organization must make available 
  6.23  upon request to the affected dentist the relevant criteria and 
  6.24  utilization data used to make the decision.  
  6.25     Subd. 4.  [REIMBURSEMENT CODES.] (a) For all dental care 
  6.26  services in which a procedural code is used by the dental 
  6.27  organization to determine coverage or reimbursement, the 
  6.28  organization must use the most recent American Dental 
  6.29  Association current dental terminology code available within a 
  6.30  year of its release.  Current dental terminology codes must be 
  6.31  used as specifically defined and must not be combined, altered, 
  6.32  or changed by either the dentist or the dental organization.  
  6.33     (b) Enrollee benefits must be determined on the basis of 
  6.34  individual codes.  
  6.35     Subd. 5.  [TREATMENT PLAN.] (a) An enrollee's dentist and 
  6.36  dental organization must provide an enrollee with accurate 
  7.1   information regarding the enrollee's condition, including, upon 
  7.2   request, a written treatment plan.  
  7.3      (b) No contractual provision between a dental organization 
  7.4   and a dentist shall in any way prohibit or limit a dentist from 
  7.5   discussing all clinical options for treatment with the patient. 
  7.6      Sec. 7.  [62Q.78] [CREDENTIALING AND PARTICIPATION OF 
  7.7   DENTISTS.] 
  7.8      Subdivision 1.  [CREDENTIALING.] Dental organizations must 
  7.9   disclose upon request to enrollees and prospective enrollees the 
  7.10  organization's credentialing criteria for participating dentists.
  7.11     Subd. 2.  [PARTICIPATION.] A dental organization must 
  7.12  disclose to any dentist, who expresses an interest in 
  7.13  participating in the organization's network, the credentialing 
  7.14  criteria and participation requirements that have been adopted 
  7.15  by the organization.