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  • Acts
  • 2005
  • Chapter 162 AN ACT RELATIVE TO DENTAL AND VISION CARE SERVICES.

Whereas , The deferred operation of this act would tend to defeat its purpose, which is to provide dental and vision care services, therefore it is hereby declared to be an emergency law, necessary for the immediate preservation of the public convenience.


Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:


SECTION 1. Section 1 of chapter 176M of the General Laws, as appearing in the 2004 Official Edition, is hereby amended by inserting after the word "dental", in line 181, the following words:- or vision.

SECTION 2. Section 1 of chapter 176N of the General Laws, as so appearing, is hereby amended by inserting after the word "credit", in line 21, the following words:- , vision.

SECTION 3. The definition of "Carrier" in section 1 of chapter 176 O of the General Laws, as so appearing, is hereby amended by adding the following sentence:- Unless otherwise noted, the term "carrier" shall not include any entity to the extent it offers a policy, certificate or contract that provides coverage solely for dental care services or visions care services.

SECTION 4. Said section 1 of said chapter 176 O, as so appearing, is hereby further amended by inserting after the definition of "Covered benefits" the following definition:

"Dental carrier", an entity that offers a policy, certificate or contract that provides coverage solely for dental care services.

SECTION 5. Said section 1 of said chapter 176 O, as so appearing, is hereby further amended by adding the following definition:-

"Vision carrier", an entity that offers a policy, certificate or contract that provides coverage solely for vision care services.

SECTION 6. Said chapter 176O is hereby further amended by striking out section 4, as so appearing, and inserting in place thereof the following section:-

Section 4. A carrier, including a dental or vision carrier, shall not refuse to contract with or compensate for covered services an otherwise eligible health, dental or vision care provider solely because such provider has in good faith communicated with or advocated on behalf of one or more of his prospective, current or former patients regarding the provisions, terms or requirements of the carrier's health, dental or vision benefit plans as they relate to the needs of such provider's patients, or communicated with 1 or more of his prospective, current or former patients with respect to the method by which such provider is compensated by the carrier for services provided to the patient. Nothing in this section shall preclude a carrier, including a dental or vision carrier, from requiring a health, dental or vision care provider to hold confidential specific compensation terms.

SECTION 7. Said chapter 176O is hereby further amended by striking out section 5, as so appearing, and inserting in place thereof the following section:-

Section 5. No contract between a carrier, including a dental or vision carrier, and a health, dental or vision care provider for the provision of services to insureds may require the provider to indemnify the carrier for any expenses and liabilities, including, without limitation, judgments, settlements, attorneys' fees, court costs and any associated charges, incurred in connection with any claim or action brought against the carrier based on the carrier's management decisions, utilization review provisions or other policies, guidelines or actions.

SECTION 8. Section 6 of said chapter 176O, as so appearing, is hereby amended by adding the following subsection:-

(b) A dental or vision carrier shall issue and deliver to at least 1 adult insured in each household residing in the commonwealth, upon enrollment, an evidence of coverage and any amendments thereto, a summary of the information contained in the evidence of coverage or refer the insured to resources where the information can be accessed, including, but not limited to, an internet website. If the dental or vision carrier chooses to deliver an evidence of coverage, it shall contain a clear, concise and complete statement of:-

(1) the dental or vision care services and any other benefits which the insured is entitled to on a nondiscriminatory basis;

(2) the limitations on the scope of dental or vision care services and any other benefits to be provided, including an explanation of any deductible or copayment feature and all restrictions relating to preexisting condition exclusions;

(3) the locations where, and the manner in which, dental or health care services and other benefits may be obtained;

(4) the criteria by which an insured may be disenrolled or denied enrollment and the involuntary disenrollment rate among insureds of the carrier;

(5) a description of the carrier's method for resolving insured complaints;

(6) the requirement that an insured's coverage may be canceled, or its renewal refused, only in the following circumstances: (i) failure by the insured or other responsible party to make payments required under the contract; (ii) misrepresentation or fraud on the part of the insured; (iii) commission of acts of physical or verbal abuse by the insured which pose a threat to providers or other insureds of the carrier and which are unrelated to the physical or mental condition of the insured; provided, that the commissioner prescribes or approves the procedures for the implementation of the provisions of this clause; (iv) relocation of the insured outside the service area of the carrier; and (v) nonrenewal or cancellation of the group contract through which the insured receives coverage;

(7) a summary description of the procedure, if any, for out of network referrals and any additional charge for using out of network providers;

(8) a summary description of the utilization review procedures and quality assurance programs used by the carrier, including the toll-free telephone number to be established by the carrier that enables consumers to determine the status or outcome of utilization review decisions;

(9) a statement detailing what translator and interpretation services are available to assist insureds. The commissioner shall determine in which languages other than English such statement shall be printed;

(10) such other information as the commissioner may by regulation require.

SECTION 9. Section 10 of said chapter 176 O, as so appearing, is hereby amended by striking out subsections (a) and (b) and inserting in place thereof the following 2 subsections:-

(a) No contract between a carrier, including a dental or vision carrier, and a licensed health, dental or vision care provider group shall contain any incentive plan that includes a specific payment made to a health, dental or vision care professional as an inducement to reduce, delay or limit specific, necessary services covered by the health, dental or vision care contract. Health, dental or vision care professionals shall not profit from provision of covered services that are not necessary and appropriate. Carriers, including a dental or vision carrier, shall not profit from denial or withholding of covered services that are necessary and appropriate. Nothing in this section shall prohibit contracts that contain incentive plans that involve general payments such as capitation payments or shared risk agreements that are made with respect to health, dental or vision providers or which are made with respect to groups of insureds if such contracts, which impose risk on such health, dental or vision providers for the costs of care, services and equipment provided or authorized by another health, dental or vision care provider, comply with subsection (b).

(b) In order that patient care decisions are based on need and not on financial incentives, no carrier, including a dental or vision carrier, shall enter into a new contract, revise the risk arrangements in an existing contract or, after July 1, 2001, revise the fee schedule in an existing contract with a health, dental or vision care provider which imposes financial risk on such provider for the costs of care, services or equipment provided or authorized by another provider unless such contract includes specific provisions with respect to the following: (1) stop loss protection, (2) minimum patient population size for the provider group, and (3) identification of the health, dental or vision care services for which the provider is at risk.

SECTION 10. Section 15 of said chapter 176 O, as so appearing, is hereby amended by striking out subsection (i) and inserting in place thereof the following subsection:-

(i) A carrier, including a dental or vision carrier, shall provide health, dental or vision care providers applying to be participating providers who are denied such status with a written reason or reasons for denial of such application.

SECTION 11. Said section 15 of said chapter 176 O, as so appearing, is hereby amended by striking out subsection (k) and inserting in place thereof the following subsection:-

(k) A carrier, including a dental or vision carrier, shall provide insureds, upon request, interpreter and translation services related to administrative procedures.

SECTION 12. This act shall take effect as of January 1, 2006.

Approved December 8, 2005.