DOC Access Act of 2021

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 of 2021 DOC Access Act of 2021 2. Improving health care coverage under vision and dental plans (a) PHSA (1) In general Part D of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg–111 2799A–11. Improving coverage under vision and dental plans (a) In general Under a group health plan or individual or group 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 that, 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 provides items or services that are not covered services under the plan or coverage to a person enrolled under such plan or coverage, 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 or 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 services under the plan or coverage only if the item or service is an item or service with respect to which the plan or coverage is obligated to pay an amount that is reasonable and is not nominal or de minimis. (C) Exception for dental cleaning For purposes of subparagraph (A), a doctor of dental surgery or doctor of dental medicine that has an agreement to participate in the plan or coverage may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan or coverage. (2) 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— (A) the agreement may be extended for a term longer than 2 years only with the prior acceptance of the doctor for each such term extension; and (B) the agreement may be extended for unlimited terms, subject to subparagraph (A). (3) No restrictions 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) Election To be excluded (1) In general If a doctor of optometry, doctor of dental surgery, or doctor of dental medicine to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan or coverage shall not apply to such plan or coverage for such period, as described in paragraph (2). (2) Period of election An election under paragraph (1)— (A) shall apply for a single specified plan year; (B) may be extended through subsequent elections under this subsection; and (C) shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). (e) Definitions In this section: (1) The term covered services (2) The terms doctor of dental surgery doctor of dental medicine (3) The term doctor of optometry . (2) 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 2799A–11, the requirements (b) ERISA (1) In general Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185 726. Improving coverage under vision and dental plans (a) In general Under a group health plan or group 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 that, 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 provides items or services that are not covered services under the plan or coverage to a person enrolled under such plan or coverage, 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 or 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 services under the plan or coverage only if the item or service is an item or service with respect to which the plan or coverage is obligated to pay an amount that is reasonable and is not nominal or de minimis. (C) Exception for dental cleaning For purposes of subparagraph (A), a doctor of dental surgery or doctor of dental medicine that has an agreement to participate in the plan or coverage may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan or coverage. (2) 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— (A) the agreement may be extended for a term longer than 2 years only with the prior acceptance of the doctor for each such term extension; and (B) the agreement may be extended for unlimited terms, subject to subparagraph (A). (3) No restrictions 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 732(c)(1) shall not apply with respect to the requirements of this section. (d) Election To be excluded (1) In general If a doctor of optometry, doctor of dental surgery, or doctor of dental medicine to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan or coverage shall not apply to such plan or coverage for such period, as described in paragraph (2). (2) Period of election An election under paragraph (1)— (A) shall apply for a single specified plan year; (B) may be extended through subsequent elections under this subsection; and (C) shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). (e) Definitions In this section: (1) The term covered services (2) The terms doctor of dental surgery doctor of dental medicine (3) The term doctor of optometry . (2) Conforming amendment Section 732(c)(1) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1191a(c)(1) The requirements Subject to section 726, the requirements (3) Clerical amendment The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1001 Sec. 726. Improving coverage under vision and dental plans. . (c) IRC (1) In general Subchapter B of chapter 100 9826. Improving coverage under vision and dental plans (a) In general Under a group health plan (including such a plan offering limited scope dental or vision benefits), the following shall apply: (1) Payment amounts from covered persons (A) In general The plan shall provide that, 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 and that provides items or services that are not covered services under the plan to a person enrolled under such plan, 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 or services considered covered by a plan For purposes of subparagraph (A), an item or service shall be considered, with respect to a plan, to be covered services under the plan only if the item or service is an item or service with respect to which the plan is obligated to pay an amount that is reasonable and is not nominal or de minimis. (C) Exception for dental cleaning For purposes of subparagraph (A), a doctor of dental surgery or doctor of dental medicine that has an agreement to participate in the plan may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan. (2) Duration of limited scope vision and dental plans In the case of an agreement between such a doctor and such a plan that offers limited scope dental or vision benefits— (A) the agreement may be extended for a term longer than 2 years only with the prior acceptance of the doctor for each such term extension; and (B) the agreement may be extended for unlimited terms, subject to subparagraph (A). (3) No restrictions on choice of laboratories The plan 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. (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 9831(c)(1) shall not apply with respect to the requirements of this section. (d) Election To be excluded (1) In general If a doctor of optometry, doctor of dental surgery, or doctor of dental medicine to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan shall not apply to such plan for such period, as described in paragraph (2). (2) Period of election An election under paragraph (1)— (A) shall apply for a single specified plan year; (B) may be extended through subsequent elections under this subsection; and (C) shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). (e) Definitions In this section: (1) The term covered services (2) The terms doctor of dental surgery doctor of dental medicine (3) The term doctor of optometry . (2) Conforming amendment Section 9831(c)(1) The requirements Subject to section 9826, the requirements (3) Clerical amendment The table of sections for subchapter B of chapter 100 Sec. 9826. Improving coverage under vision and dental plans. . 3. Exclusive applicability of State law Notwithstanding any amendment made by this Act, State law that directly affects any standard or requirement relating to health insurance issuers and dental or vision benefit plans, shall have exclusive application and the amendments made by this Act shall not apply to the extent that such State law conflicts with such amendments. The State shall retain exclusive jurisdiction over health insurance issuers and limited scope dental or vision benefit plans that are directly governed by such State.

Summary: Dentist and Optometric Care Access Act of 2021 or the DOC Access Act of 2021 This bill prohibits private health insurance plans from setting rates for items and services, except for dental cleanings, provided by a doctor of optometry, of dental surgery, or of dental medicine for which the plan does not pay a substantial amount. Additionally, an agreement between a plan and such a doctor for limited scope dental or vision benefits may last longer than two years only with the prior acceptance of the doctor for each term extension. Plans also may not restrict such a doctor's choice of laboratories or suppliers. Such doctors may elect to waive the application of the payment amount and choice of laboratories provisions of this bill. The bill establishes a private right of action for a person adversely affected by a violation of this bill. The bill does not supersede state laws regarding health insurers and dental or vision benefit plans.