CDA Stops Dental Plans from Setting Fees for Services They Don’t Cover

Molly Pereira Featured News

The CDA secured passage of SB 190 during the 2017 state legislative session.

From the Summer 2017 Journal of the Colorado Dental Association

In April, after years of policy discussions on the topic, Colorado Gov. John Hickenlooper signed into law SB 190, a bill that requires dental plans to stop dictating fees for services they do not cover. This practice has been an ongoing concern for CDA member dentists for many years, as it can disrupt patient choice of dental services and the patient-provider relationship. It can also interfere in the fair delivery of dental services for patients across the state, creating cost shifting and barriers to care. SB 190 will offer more flexible care options to member dentists and their patients.

The passage of SB 190 sets in motion an important first step in broad conversations on insurance reform and the future of dental benefits that will be happening in coming years. The CDA remains committed to support reforms that ensure equitable treatment of dentists, preserve high quality care, and increase patient access to dental services.

SB 190: What You Need to Know

SB 190 prohibits dental plans from setting fees for services that are not ever covered by a patient’s specific plan. SB 190 does not change carrier fee obligations for covered services. For covered services, negotiated rates continue to apply. In addition, services that would be a covered service if the patient had not met a frequency limitation, a waiting period, an annual maximum, or similar covered service restriction continue to be subject to negotiated carrier rates.

Specific noncovered services will vary by carrier and even by specific dental plan. The key to determining whether a service is considered “noncovered” depends on whether the patient’s specific plan would ever reimburse for the service at the beginning of the patient’s benefit year or when the patient’s benefit is unrestricted. If the plan would not reimburse anything for the service even in this circumstance, it is likely a “noncovered service.”

Starting Aug. 9, 2017, when a dentist provides a noncovered service to a patient, the dentist is permitted to bill the patient for the service in an amount that is less than or equal to the dentist’s UCR for uninsured patients. The patient needs to consent to the fee, and dentists are encouraged to obtain and maintain documentation of this financial consent in records (for example, a signed treatment plan that reasonably estimates the costs of the procedure).