I 

112TH CONGRESS 

1ST SESSION H. R. 1809 

To amend the Employee Retirement Income Security Act of 1974 to ensure 

health care coverage value and transparency for dental benefits under 

group health plans. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 10, 2011 

Mr. ANDREWS (for himself, Mr. YOUNG of Alaska, and Mr. GOSAR) introduced 

the following bill; which was referred to the Committee on Education and 

the Workforce 

A BILL 

To amend the Employee Retirement Income Security Act 

of 1974 to ensure health care coverage value and transparency for dental benefits under group health plans. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Dental Coverage Value 

5 and Transparency Act of 2011’’. 

6 SEC. 2. VALUE AND TRANSPARENCY REQUIREMENTS FOR 

7 DENTAL BENEFITS. 

8 (a) IN GENERAL.—Subpart B of part 7 of subtitle 

9 A of title I of the Employee Retirement Income Security 


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1 Act of 1974 is amended by adding at the end the following 

2 new section: 

3 ‘‘SEC. 716. VALUE AND TRANSPARENCY REQUIREMENTS 

4 FOR DENTAL BENEFITS. 

5 ‘‘(a) IN GENERAL.—The requirements of this section 

6 shall apply to group health plans insofar as they provide 

7 dental benefits (including, notwithstanding section 

8 732(c)(1), limited scope dental benefits (described in sec9 tion 733(c)(2))), directly, through health insurance cov10 erage, or otherwise. 

11 ‘‘(b) VALUE.—In order to ensure that participants 

12 and beneficiaries in a group health plan receive full value 

13 from dental benefits, the plan shall meet the following re14 quirements: 

15 ‘‘(1) UNIFORM COORDINATION OF BENEFITS.— 

16 The plan shall provide for coordination of benefits in 

17 a manner so that the plan pays the same amount re18 gardless of other coverage for such benefits so long 

19 as the total amount paid does not exceed 100 per20 cent of the amount of the applicable claim. Such co21 ordination shall be effected consistent with such 

22 rules as the Secretary establishes, based upon simi23 lar model regulations developed by the National As24 sociation of Insurance commissioners. 


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1 ‘‘(2) EQUITY FOR OUT-OF-NETWORK PRO2 VIDERS THROUGH ASSIGNMENT OF BENEFITS AND

3 COMPARABLE PAYMENTS.—In the case of a plan 

4 that provides dental benefits through a network of 

5 providers, the plan shall— 

6 ‘‘(A) permit a participant or beneficiary to 

7 designate payment of dental benefits to a pro8 vider who is not participating in the network; 

9 ‘‘(B) provide the same dollar amount of 

10 coverage for a given procedure regardless of 

11 whether the provider of the procedure is partici12 pating in the network; and 

13 ‘‘(C) not permit the application of the 

14 plan’s or network’s fee schedule to services for 

15 which no benefits or reimbursement are pro16 vided. 

17 ‘‘(c) TRANSPARENCY.—In order to ensure trans18 parency in the provision of dental benefits to participants 

19 and beneficiaries in a group health plan, the plan shall 

20 meet the following requirements: 

21 ‘‘(1) PROHIBITION OF BUNDLING AND DOWN

22 CODING.—The plan shall not— 

23 ‘‘(A) systematically combine distinct dental 

24 procedures codes in a manner that results in a 

25 reduced benefit under the plan; or 


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1 ‘‘(B) provide for a change in the benefit 

2 code to a less complex (or lower cost) procedure 

3 than was reported if such actions are incon4 sistent with the current dental terminology 

5 (CDT) or, for a provider participating in a net6 work, inconsistent with the terms of the net7 work participation agreement. 

8 ‘‘(2) FAIR PAYMENT TERMS.—The plan shall— 

9 ‘‘(A) provide for payment of interest (at a 

10 rate specified by the Secretary) or other penalty 

11 for clean claims paid more than 30 days after 

12 the date of their submission; 

13 ‘‘(B) not seek collection of overpayments 

14 more than 90 days after the date of the over15 payment; and 

16 ‘‘(C) not recover overpayments for a dental 

17 procedure by withholding payments for unre18 lated procedures. 

19 ‘‘(3) TRANSPARENCY IN USE OF LEASE NET20 WORKS.—A plan may use a network that is leased 

21 by a health insurance issuer or other entity to an22 other such issuer or entity (where such leasing is 

23 permitted by the contract between a provider and 

24 the issuer or other entity) only if the contract lanVerDate Mar 15 2010 06:06 May 12, 2011 Jkt 099200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H1809.IH H1809

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1 guage describes in a manner understandable to the 

2 average dental provider the terms of such leasing,’’. 

3 (b) CONFORMING AMENDMENT.—The table of con4 tents of such Act is amended by inserting after the item 

5 relating to section 715 the following new item: 

‘‘Sec. 716. Value and transparency requirements for dental benefits.’’. 

6 (c) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to plan years beginning more than 

8 1 year after the date of the enactment of this Act. 

Æ 


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