2nd Engrossment - 81st Legislature (1999 - 2000) Posted on 12/15/2009 12:00am
1.1 A bill for an act 1.2 relating to health; regulating dental benefit plans; 1.3 proposing coding for new law in Minnesota Statutes, 1.4 chapter 62Q. 1.5 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA: 1.6 Section 1. [62Q.75] [DEFINITIONS.] 1.7 Subdivision 1. [APPLICABILITY.] For purposes of sections 1.8 62Q.75 to 62Q.78, the terms defined in this section have the 1.9 meanings given them. 1.10 Subd. 2. [DENTAL CARE SERVICES.] "Dental care services" 1.11 means services performed by a licensed dentist or any person 1.12 working under the dentist's supervision as permitted under 1.13 chapter 150A, which an enrollee might reasonably require to 1.14 maintain good dental health, including preventive services, 1.15 diagnostic services, emergency dental care, and restorative 1.16 services. 1.17 Subd. 3. [DENTAL PLAN.] "Dental plan" means a policy, 1.18 contract, or certificate offered by a dental organization for 1.19 the coverage of dental care services. Dental plan means 1.20 individual or group coverage. 1.21 Subd. 4. [DENTIST.] "Dentist" means a person licensed to 1.22 practice dentistry under chapter 150A. 1.23 Subd. 5. [EMERGENCY DENTAL CARE.] "Emergency dental care" 1.24 means the provision of dental care services for a sudden, acute 1.25 dental condition that would lead a prudent layperson to 2.1 reasonably expect that the absence of immediate care would 2.2 result in serious impairment to the dentition or would place the 2.3 person's oral health in serious jeopardy. 2.4 Subd. 6. [ENROLLEE.] "Enrollee" means an individual 2.5 covered by a dental organization and includes an insured, 2.6 policyholder, subscriber, contract holder, member, covered 2.7 person, or certificate holder. 2.8 Subd. 7. [DENTAL ORGANIZATION.] "Dental organization" 2.9 means a health insurer licensed under chapter 60A; a health 2.10 service plan corporation licensed under chapter 62C; a health 2.11 maintenance organization licensed under chapter 62D; a community 2.12 integrated service network licensed under chapter 62N; or a 2.13 third party administrator that: 2.14 (i) provides, either directly or through contracts with 2.15 providers or other persons, dental care services; 2.16 (ii) arranges for the provision of these services to 2.17 enrollees on the basis of a fixed prepaid sum without regard to 2.18 the frequency or extent of services furnished to any particular 2.19 enrollee; or 2.20 (iii) administers dental plans. 2.21 Sec. 2. [62Q.76] [TERMS OF COVERAGE DISCLOSURE.] 2.22 A dental organization shall make available to an enrollee, 2.23 upon request, a clear and concise description of the following 2.24 terms of coverage: 2.25 (1) the dental care services and other benefits to which 2.26 the enrollee is entitled under the dental plan; 2.27 (2) any exclusions or limitation on the services, kind of 2.28 services, benefits, or kind of benefits to be provided, 2.29 including any deductible or copayment features and any 2.30 requirements for referrals to specialists; 2.31 (3) a description as to how services, including emergency 2.32 dental care and out-of-area service, may be obtained; 2.33 (4) a general description of payment and copayment amounts, 2.34 if any, for dental care services, which the enrollee is 2.35 obligated to pay; and 2.36 (5) a telephone number by which the enrollee may obtain 3.1 additional information regarding coverage. 3.2 Sec. 3. [62Q.77] [DENTAL BENEFIT PLAN REQUIREMENTS.] 3.3 Subdivision 1. [UTILIZATION PROFILING.] (a) A dental 3.4 organization that uses utilization profiling as a method of 3.5 differentiating provider reimbursement or as a requirement for 3.6 continued participation in the organization's provider network 3.7 shall, upon request, make available to participating dentists 3.8 the following information: 3.9 (i) a description of the methodology used in profiling so 3.10 that dentists can clearly understand why and how they are 3.11 affected; and 3.12 (ii)(A) a list of the codes measured; (B) a dentist's 3.13 personal frequency data within each code so that the accuracy of 3.14 the data can be verified; and (C) an individual dentist's 3.15 representation of scoring compared to classification points and 3.16 how the dentist compares with peers in each category including 3.17 the cutoff point of the score impacting qualification in order 3.18 to inform the dentist about how the dentist may qualify or 3.19 retain qualification for differentiated provider reimbursement 3.20 or continued participation in the dental organization's provider 3.21 network. 3.22 (b) A dental organization that uses utilization profiling 3.23 as a method of differentiating provider reimbursement or as a 3.24 requirement for continued participation in the organization's 3.25 provider network shall, upon request, provide a clear and 3.26 concise description of the methodology of the utilization 3.27 profiling on dental benefits to group purchasers and enrollees. 3.28 (c) A dental organization shall not be considered to be 3.29 engaging in the practice of dentistry pursuant to chapter 150A, 3.30 to the extent it releases utilization profiling information as 3.31 required by sections 62Q.75 to 62Q.78. 3.32 Subd. 2. [REIMBURSEMENT CODES.] (a) Unless the federal 3.33 government requires the use of other procedural codes, for all 3.34 dental care services in which a procedural code is used by the 3.35 dental organization to determine coverage or reimbursement, the 3.36 organization must use the most recent American Dental 4.1 Association current dental terminology code that is available, 4.2 within a year of its release. Current dental terminology codes 4.3 must be used as specifically defined, must be listed separately, 4.4 and must not be altered or changed by either the dentist or the 4.5 dental organization. 4.6 (b) Enrollee benefits must be determined on the basis of 4.7 individual codes subject to provider and group contracts. 4.8 (c) This subdivision does not prohibit or restrict dental 4.9 organizations from setting reimbursement and pricing with 4.10 groups, purchasers, and participating providers or addressing 4.11 issues of fraud or errors in claims submissions. 4.12 Subd. 3. [TREATMENT OPTIONS.] No contractual provision 4.13 between a dental organization and a dentist shall in any way 4.14 prohibit or limit a dentist from discussing all clinical options 4.15 for treatment with the patient. 4.16 Sec. 4. [62Q.78] [LIMITATIONS.] 4.17 (a) The provisions contained in section 62Q.76 shall not 4.18 require a dental organization to disclose information which the 4.19 dental organization is already obligated to disclose under 4.20 applicable Minnesota law governing the operation of the dental 4.21 organization. 4.22 (b) Any information a dental organization is required to 4.23 disclose or communicate under section 62Q.76 to its subscribers, 4.24 enrollees, participating providers, contracting groups, or 4.25 dentists may be accomplished by electronic communication 4.26 including, but not limited to, e-mail, the Internet, Web sites, 4.27 and employer electronic bulletin boards. 4.28 Sec. 5. [EFFECTIVE DATE.] 4.29 Section 62Q.77, subdivision 2, is effective August 1, 2001.