BILL NUMBER: AB 2275	AMENDED
	BILL TEXT

	AMENDED IN SENATE  JULY 15, 2010
	AMENDED IN SENATE  JUNE 10, 2010

INTRODUCED BY   Assembly Member Hayashi
    (   Coauthor:   Assembly Member  
Ma   ) 
   (Coauthor: Senator Aanestad)

                        FEBRUARY 18, 2010

   An act to add Section 1374.195 to the Health and Safety Code, and
to add Section 10120.3 to the Insurance Code, relating to health care
coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 2275, as amended, Hayashi. 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  plan contracts and
policies that cover dental services, prohibit a plan or insurer 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
unless the dental care services are covered services under the plan
contract or policy, as specified   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 contract. The bill
would also prohibit a provider from charging more than his or her
usual and customary rate for dental services not covered under the
contract or policy  .
   Because a willful violation of this prohibition 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.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1374.195 is added to the Health and Safety
Code, to read: 
   1374.195.  (a) With respect to a health care service plan contract
covering dental services or a specialized health care service plan
contract covering dental services pursuant to this chapter, the plan
shall not require a dentist to accept an amount set by the plan as
payment for dental care services provided to an enrollee unless the
dental care services are covered services under the enrollee's plan
contract. 
    1374.195.   (a)  With respect to a contract between
a health care service plan or specialized health care service plan
and a dentist to provide covered dental services to enrollees of the
plan, the contract shall not require a dentist to accept an amount
set by the plan as payment for dental care services provided to an
enrollee that are not covered services under the enrollee's plan
contract. 
   (b) For purposes of this section, "covered services"  or
"covered dental services"  means dental care services for which
 a reimbursement is available under an enrollee's plan
contract   the plan is, pursuant to provider contracts,
obligated to pay  , or for which  a reimbursement would
be available   the plan would be obligated to pay 
but for the application of contractual limitations such as
deductibles, copayments, coinsurance, waiting periods, annual or
lifetime maximums, frequency limitations,  or  alternative
benefit  payments, or any other limitation.  
payments. 
   (c) This section shall only apply to provider contracts issued,
revised, or renewed on or after January 1, 2011. 
   (d) This section shall not apply to a discount health plan
provider agreement regulated by the department under subdivision (a)
of Section 1341.  
   (d) A provider shall not charge more for dental services that are
not covered services under the contract than his or her usual and
customary rate for those services. 
  SEC. 2.  Section 10120.3 is added to the Insurance Code, to read:

   10120.3.  (a) With respect to a health insurance policy covering
dental services or a specialized health insurance policy covering
dental services pursuant to this code, the insurer shall not require
a dentist to accept an amount set by the insurer as payment for
dental care services provided to an insured unless the dental care
services are covered services under the insured's policy. 
    10120.3.   (a) With respect to a contract between an
insurer covering dental services and a dentist to provide covered
dental services to insureds, the contract shall not require a dentist
to accept an amount set by the insurer as payment for dental care
services provided to an insured that are not covered services under
the insured's policy. 
   (b) For purposes of this section, "covered services" means dental
care services for which  a  reimbursement  by
the insurer  is available under an insured's policy, or for
which a reimbursement would be available but for the application of
contractual limitations such as deductibles, copayments, coinsurance,
waiting periods, annual or lifetime maximums, frequency limitations,
 or  alternative benefit  payments, or any other
limitation.   payments. 
   (c) This section shall only apply to provider contracts issued,
revised, or renewed on or after January 1, 2011. 
   (d) This section shall not apply to a discount health plan
provider agreement regulated by the Department of Managed Health Care
under subdivision (a) of Section 1341 of the Health and Safety Code.
 
   (d) A provider shall not charge more for dental services that are
not covered services under the contract or policy than his or her
usual and customary rate for those services. 
  SEC. 3.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.