Chief Sponsor: James A. Dunnigan

Senate Sponsor: Karen Mayne


8     General Description:
9          This bill regulates dental claims and dental leasing contracts.
10     Highlighted Provisions:
11          This bill:
12          ▸     defines terms;
13          ▸     describes when an insurer may use bundling and downcoding;
14          ▸     describes when a third party may lease a dental plan network;
15          ▸     describes requirements for a dental lease contract; and
16          ▸     allows a dental provider to opt out of a lease if leased by an insurer.
17     Money Appropriated in this Bill:
18          None
19     Other Special Clauses:
20          None
21     Utah Code Sections Affected:
22     ENACTS:
23          31A-22-646.1, Utah Code Annotated 1953
24          31A-26-301.7, Utah Code Annotated 1953

26     Be it enacted by the Legislature of the state of Utah:
27          Section 1. Section 31A-22-646.1 is enacted to read:
28          31A-22-646.1. Leasing requirements for dental plans.

29          (1) As used in this section:
30          (a) "Contracting entity" means a person that enters into a direct contract with a provider
31     for the delivery of dental services in the ordinary course of business, including a third party
32     administrator or a dental carrier.
33          (b) "Dental carrier" means a dental insurance company, dental service corporation, or
34     dental plan organization authorized to provide a dental plan.
35          (c) "Dental plan" means the same as that term is defined in Section 31A-22-646.
36          (d) (i) "Dental services" means services for the diagnosis, prevention, treatment, or
37     cure of a dental condition, illness, injury, or disease.
38          (ii) "Dental services" does not include services that a provider delivers and bills as
39     medical expenses under a health benefit plan.
40          (e) (i) "Dental service contractor" means an individual who:
41          (A) accepts prepayment for dental services; or
42          (B) for the benefit of another individual, accepts payment for providing to the
43     individual the opportunity to receive dental services in the future.
44          (ii) "Dental service contractor" does not include a provider or professional dental
45     corporation that accepts prepayment on a fee-for-service basis for providing specific dental
46     services to individual patients for whom the services have been pre-diagnosed.
47          (f) (i) "Provider" means a person who, acting within the scope of licensure or
48     certification, provides dental services or supplies defined by the dental plan.
49          (ii) "Provider" does not include a physician organization or physician hospital
50     organization that leases or rents the physician organization's or physician hospital
51     organization's network to a third party.
52          (g) "Provider network contract" means a contract between a contracting entity and a
53     provider that:
54          (i) specifies the rights and responsibilities of the contracting entity; and
55          (ii) provides for the delivery and payment of dental services to an enrollee.

56          (h) (i) "Third party" means a person that enters into a contract with a contracting entity
57     or with another third party to gain access to the dental services or contractual discounts of a
58     provider network contract.
59          (ii) "Third party" does not include an employer or other group for whom the dental
60     carrier or contracting entity provides administrative services.
61          (2) A contracting entity may grant a third party access to a provider network contract
62     regarding dental services, including a provider's dental services, or a contractual discount
63     provided under a provider network contract for dental services if:
64          (a) if the contracting entity is an insurer, the insurer complies with Subsection (3);
65          (b) the contract between the contracting entity and a person subject to the third-party
66     access complies with Subsection (4); and
67          (c) the contracting entity complies with Subsection (5).
68          (3) An insurer shall:
69          (a) at the time a contract is entered into or renewed, or when there is a material
70     modification to a contract that is relevant to third-party access to a provider network contract,
71     allow a provider which is part of the insurer's provider network to:
72          (i) choose to not participate in third-party access; or
73          (ii) enter into a contract directly with the third party that acquired the provider network;
74          (b) allow a provider to opt out of lease arrangements without canceling or ending a
75     contractual relationship with the insurer; and
76          (c) when initially contracting with a provider, accept a qualified provider even if a
77     provider rejects a network lease provision.
78          (4) A contracting entity described in Subsection (2) shall ensure that the contract
79     described in Subsection (2)(b) includes the following:
80          (a) a provision indicating the contracting entity may enter into an agreement with a
81     third party to allow the third party to obtain the contracting entity's rights and responsibilities as
82     if the third party were the contracting entity;

83          (b) if the contracting entity is a dental carrier, a provision indicating that the provider
84     chose to participate in third-party access at the time the provider network contract was entered
85     into or renewed; and
86          (c) if the contracting entity is an insurer, a provision indicating:
87          (i) that the contract grants a third party access to the provider network; and
88          (ii) for a contract with a dental carrier, the dentist has the right to choose not to
89     participate in third-party access.
90          (5) A contracting entity shall:
91          (a) provide a provider, in writing or electronic form, each third party in existence as of
92     the date the contract is entered into;
93          (b) maintain a list of each third party in existence on the contracting entity's website
94     that is updated at least once every 90 days;
95          (c) require a third party to identify the source of the discount on all remittance advices
96     or explanations of payment under which a discount is taken unless the transaction is an
97     electronic transaction mandated by the Health Insurance Portability and Accountability Act;
98          (d) notify a third party of the termination of a provider network contract no later than
99     30 days after the day on which the contract terminates with the contracting entity;
100          (e) at least 30 days before the day on which a third party begins leasing a network
101     provider, notify each network provider subject to the lease;
102          (f) make available to a participating provider, within 30 days after the day on which the
103     provider makes a request, a copy of the provider network contract at issue in the adjudication
104     of a claim; and
105          (g) maintain a list of the contracting entity's affiliates on the contracting entity's
106     website.
107          (6) A third party that gains access to a contract under this section:
108          (a) shall comply with each term of the contract to which the third party gains access;
109     and

110          (b) loses all rights to a provider's discounted rate as of the termination date of the
111     provider network contract.
112          (7) A contracting entity or third party may not require a provider to perform services
113     under a provider network contract if a third party gains access to a contract in violation of this
114     section.
115          (8) This section does not apply to:
116          (a) a contracting entity granting access to a provider network contract to:
117          (i) an entity that operates in accordance with the brand licensee program of the
118     contracting entity; or
119          (ii) an entity that is an affiliate of the contracting entity; and
120          (b) a provider network contract for dental services provided to beneficiaries of a state
121     sponsored health program, including Medicaid and the Children's Health Insurance Program.
122          (9) A contract executed or renewed on or after January 1, 2022:
123          (a) may not waive the provisions of this section; and
124          (b) is null and void if the contract contains provisions that conflict with the provisions
125     of this section or that purports to waive a requirement of this section.
126          Section 2. Section 31A-26-301.7 is enacted to read:
127          31A-26-301.7. Dental claim transparency.
128          (1) As used in this section:
129          (a) "Bundling" means the practice of combining distinct dental procedures into one
130     procedure for billing purposes.
131          (b) "Dental plan" means the same as that term is defined in Section 31A-22-646.
132          (c) "Downcoding" means the adjustment of a claim submitted to a dental plan to a less
133     complex or lower cost procedure code.
134          (d) "Covered services" means the same as that term is defined in Section 31A-22-646.
135          (e) "Material change" means a change to:
136          (i) a dental plan's rules, guidelines, policies, or procedures concerning payment for

137     dental services;
138          (ii) the general policies of the dental plan that affect a reimbursement paid to providers;
139     or
140          (iii) the manner by which a dental plan adjudicates and pays a claim for services.
141          (2) An insurer that contracts or renews a contract with a dental provider shall:
142          (a) make a copy of the insurer's current dental plan policies available online; and
143          (b) if requested by a provider, send a copy of the policies to the provider through mail
144     or electronic mail.
145          (3) Dental policies described in Subsection (2) shall include:
146          (a) a summary of all material changes made to a dental plan since the policies were last
147     updated;
148          (b) the downcoding and bundling policies that the insurer reasonably expects to be
149     applied to the dental provider or provider's services as a matter of policy; and
150          (c) a description of the dental plan's utilization review procedures, including:
151          (i) a procedure for an enrollee of the dental plan to obtain review of an adverse
152     determination in accordance with Section 31A-22-629; and
153          (ii) a statement of a provider's rights and responsibilities regarding the procedures
154     described in Subsection (3)(c)(i).
155          (4) An insurer may not maintain a dental plan that:
156          (a) based on the provider's contracted fee for covered services, uses downcoding in a
157     manner that prevents a dental provider from collecting the fee for the actual service performed
158     from either the plan or the patient; or
159          (b) uses bundling in a manner where a procedure code is labeled as nonbillable to the
160     patient unless, under generally accepted practice standards, the procedure code is for a
161     procedure that may be provided in conjunction with another procedure.
162          (5) An insurer shall ensure that an explanation of benefits for a dental plan includes the
163     reason for any downcoding or bundling result.