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 trans-
parency for dental benefits under group health plans. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Dental Coverage Value 
and Transparency Act of 2011’’. 
SEC. 2. VALUE AND TRANSPARENCY REQUIREMENTS FOR 
DENTAL BENEFITS. 
(a) IN GENERAL.—Subpart B of part 7 of subtitle 
A of title I of the Employee Retirement Income Security 
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Act of 1974 is amended by adding at the end the following 
new section: 
‘‘SEC. 716. VALUE AND TRANSPARENCY REQUIREMENTS 
FOR DENTAL BENEFITS. 
‘‘(a) IN GENERAL.—The requirements of this section 
shall apply to group health plans insofar as they provide 
dental 
benefits 
(including, 
notwithstanding 
section 
732(c)(1), limited scope dental benefits (described in sec-
tion 733(c)(2))), directly, through health insurance cov-
erage, or otherwise. 
‘‘(b) VALUE.—In order to ensure that participants 
and beneficiaries in a group health plan receive full value 
from dental benefits, the plan shall meet the following re-
quirements: 
‘‘(1) UNIFORM COORDINATION OF BENEFITS.— 
The plan shall provide for coordination of benefits in 
a manner so that the plan pays the same amount re-
gardless of other coverage for such benefits so long 
as the total amount paid does not exceed 100 per-
cent of the amount of the applicable claim. Such co-
ordination shall be effected consistent with such 
rules as the Secretary establishes, based upon simi-
lar model regulations developed by the National As-
sociation of Insurance commissioners. 
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‘‘(2) EQUITY
FOR
OUT-OF-NETWORK
PRO-
VIDERS THROUGH ASSIGNMENT OF BENEFITS AND 
COMPARABLE
PAYMENTS.—In the case of a plan 
that provides dental benefits through a network of 
providers, the plan shall— 
‘‘(A) permit a participant or beneficiary to 
designate payment of dental benefits to a pro-
vider who is not participating in the network; 
‘‘(B) provide the same dollar amount of 
coverage for a given procedure regardless of 
whether the provider of the procedure is partici-
pating in the network; and 
‘‘(C) not permit the application of the 
plan’s or network’s fee schedule to services for 
which no benefits or reimbursement are pro-
vided. 
‘‘(c) TRANSPARENCY.—In order to ensure trans-
parency in the provision of dental benefits to participants 
and beneficiaries in a group health plan, the plan shall 
meet the following requirements: 
‘‘(1) PROHIBITION OF BUNDLING AND DOWN 
CODING.—The plan shall not— 
‘‘(A) systematically combine distinct dental 
procedures codes in a manner that results in a 
reduced benefit under the plan; or 
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‘‘(B) provide for a change in the benefit 
code to a less complex (or lower cost) procedure 
than was reported if such actions are incon-
sistent with the current dental terminology 
(CDT) or, for a provider participating in a net-
work, inconsistent with the terms of the net-
work participation agreement. 
‘‘(2) FAIR PAYMENT TERMS.—The plan shall— 
‘‘(A) provide for payment of interest (at a 
rate specified by the Secretary) or other penalty 
for clean claims paid more than 30 days after 
the date of their submission; 
‘‘(B) not seek collection of overpayments 
more than 90 days after the date of the over-
payment; and 
‘‘(C) not recover overpayments for a dental 
procedure by withholding payments for unre-
lated procedures. 
‘‘(3) TRANSPARENCY IN USE OF LEASE NET-
WORKS.—A plan may use a network that is leased 
by a health insurance issuer or other entity to an-
other such issuer or entity (where such leasing is 
permitted by the contract between a provider and 
the issuer or other entity) only if the contract lan-
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guage describes in a manner understandable to the 
average dental provider the terms of such leasing,’’. 
(b) CONFORMING AMENDMENT.—The table of con-
tents of such Act is amended by inserting after the item 
relating to section 715 the following new item: 
‘‘Sec. 716. Value and transparency requirements for dental benefits.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to plan years beginning more than 
1 year after the date of the enactment of this Act. 
Æ 
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