DOC Access Act

To amend title XXVII of the Public Health Service Act to improve health care coverage under vision and dental plans, and for other purposes. 1. Short title This Act may be cited as the Dental and Optometric Care Access Act DOC Access Act 2. Improving health care coverage under vision and dental plans (a) In general Title XXVII of the Public Health Service Act is amended by inserting after section 2719A ( 42 U.S.C. 300gg–19a 2719B. Improving coverage under vision and dental plans (a) In general Under a group health plan or individual or health insurance coverage (including such a plan or coverage offering limited scope dental or vision benefits), the following shall apply: (1) Payment amounts from covered persons (A) In general The plan or coverage shall provide, with respect to a doctor of optometry, doctor of dental surgery, or doctor of dental medicine that has an agreement to participate in the plan or coverage and that furnishes items or services that are not covered by the plan or coverage to a person enrolled under such plan or coverage, that the doctor may charge the enrollee for such items or services any amount determined by the doctor that is equal to, or less than, the usual and customary amount that the doctor charges individuals who are not so enrolled for such items or services. (B) Items and services considered covered by a plan For purposes of subparagraph (A), an item or service shall be considered, with respect to a plan or coverage, to be covered by the plan or coverage only if the negotiated rate agreed to by such plan or coverage and the doctor for such item or service, without regard to any cost sharing obligation of the enrollee, is an amount that is reasonable and is not nominal or de minimis. (2) Changes to plans The terms of an agreement between such a plan or coverage and such a doctor (including, in the case of a plan or coverage that provides for a provider network, the negotiated rate for providers that participate in the network of such plan or coverage), may be changed only pursuant to a subsequent agreement signed by the doctor that documents the acknowledgment and acceptance of the doctor (as applicable) to such changes. (3) Duration of limited scope vision and dental plans In the case of an agreement between such a doctor and such a plan or coverage that offers limited scope dental or vision benefits, the agreement may not be for a period that is greater than two years. (4) Terms and conditions for ancillary services and procedures Such plan or coverage may not deny such a doctor participation in the plan or coverage or remove such a doctor from participation in the plan or coverage for the sole reason of the failure of the doctor to accept the terms and conditions under such agreement for any ancillary service or procedure. (5) Condition to join a provider network The plan or coverage may not require that such a doctor must participate with, or be credentialed by, any specific plan or coverage offering limited scope dental or vision benefits as a condition to participate in the provider network of such plan or coverage. (6) No interference with existing relationships and requirements Unless otherwise required by law or regulation, such plan or coverage may not directly communicate with an individual enrolled in such plan or coverage in a manner that interferes with or contravenes any State or Federal requirement, or doctor-patient relationship in existence at the time of such communication. (7) No restriction on choice of laboratories The plan or coverage may not, directly or indirectly, restrict or limit, such a doctor’s choice of laboratories or choice of source and suppliers of services or materials provided by the doctor to an individual who is enrolled under the plan or coverage. (b) Private right of action In addition to any other remedies under State or Federal law, a person adversely affected by a violation of this subsection may bring action for injunctive relief against a plan described in subsection (a) and, upon prevailing, in addition to such injunctive relief, shall recover monetary damages of no more than $1,000 for each day found to be in violation plus attorney’s fees and costs. The district courts of the United States shall have exclusive jurisdiction of civil actions brought under this subsection. (c) Relationship to exception for limited, excepted benefits Section 2722(c)(1) shall not apply with respect to the requirements of this section. (d) Definitions In this section: (1) The terms doctor of dental surgery doctor of dental medicine (2) The term doctor of optometry . (b) Conforming amendment Section 2722(c)(1) of the Public Health Service Act ( 42 U.S.C. 300gg–21(c)(1) The requirements Subject to section 2719B, the requirements

Summary: Dental and Optometric Care Access Act or the DOC Access Act This bill amends the Public Health Service Act to prohibit group health plans and individual health insurance coverage from setting rates for items and services provided by a doctor of optometry, of dental surgery, or of dental medicine for which the plan or insurer does not pay a substantial amount. An agreement between a plan or insurer and such a doctor: (1) may only be changed with the doctor's acknowledgement and acceptance, and (2) may not last longer than two years if the agreement is for limited scope dental or vision benefits. Such a doctor must be allowed to participate in a: (1) plan or coverage without accepting terms for ancillary services or procedures, and (2) provider network without participating in a specific limited scope dental or vision benefit plan. Plans and insurers may not: (1) directly communicate with an enrolled individual in a manner that interferes with an existing doctor-patient relationship or a state or federal requirement, or (2) restrict such a doctor's choice of laboratories or suppliers. The bill establishes a private right of action for a person adversely affected by a violation of this Act.