DOC Access Act of 2021
Bill: S.1793 | Sponsor: Sen. Manchin, Joe, III (D-WV)
Policy area: Health

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.

To amend title XXVII of the Public Health Service Act to improve health 
  care coverage under vision and dental plans, and for other purposes.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Dental and Optometric Care Access 
Act of 2021'' or the ``DOC Access Act of 2021''.

SEC. 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 et seq.) is amended by adding 
        at the end the following:

``SEC. 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' means dental care or 
        vision care services for which reimbursement is available under 
        a plan or coverage contract, or for which reimbursement would 
        be available but for the application of contractual 
        limitations, including deductibles, copayments, coinsurance, 
        waiting periods, lifetime maximum, frequency limitations, and 
        alternative benefit payments.
            ``(2) The terms `doctor of dental surgery' and `doctor of 
        dental medicine' mean a doctor of dental surgery or of dental 
        medicine, as applicable, who is legally authorized to practice 
        dentistry by the State in which the doctor performs such 
        function and who is acting within the scope of the license of 
        the doctor when performing such functions.
            ``(3) The term `doctor of optometry' means a doctor of 
        optometry who is legally authorized to practice optometry by 
        the State in which the doctor so practices.''.
            (2) Conforming amendment.--Section 2722(c)(1) of the Public 
        Health Service Act (42 U.S.C. 300gg-21(c)(1)) is amended by 
        striking ``The requirements'' and inserting ``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 et seq.) is amended by adding at the end the 
        following:

``SEC. 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' means dental care or 
        vision care services for which reimbursement is available under 
        a plan or coverage contract, or for which reimbursement would 
        be available but for the application of contractual 
        limitations, including deductibles, copayments, coinsurance, 
        waiting periods, lifetime maximum, frequency limitations, and 
        alternative benefit payments.
            ``(2) The terms `doctor of dental surgery' and `doctor of 
        dental medicine' mean a doctor of dental surgery or of dental 
        medicine, as applicable, who is legally authorized to practice 
        dentistry by the State in which the doctor performs such 
        function and who is acting within the scope of the license of 
        the doctor when performing such functions.
            ``(3) The term `doctor of optometry' means a doctor of 
        optometry who is legally authorized to practice optometry by 
        the State in which the doctor so practices.''.
            (2) Conforming amendment.--Section 732(c)(1) of the 
        Employee Retirement Income Security Act of 1974 (29 U.S.C. 
        1191a(c)(1)) is amended by striking ``The requirements'' and 
        inserting ``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 et seq.) is amended by inserting after the item 
        relating to section 725 the following:

``Sec. 726. Improving coverage under vision and dental plans.''.
    (c) IRC.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986 is amended by adding at the end 
        the following:

``SEC. 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' means dental care or 
        vision care services for which reimbursement is available under 
        a plan contract, or for which reimbursement would be available 
        but for the application of contractual limitations, including 
        deductibles, copayments, coinsurance, waiting periods, lifetime 
        maximum, frequency limitations, and alternative benefit 
        payments.
            ``(2) The terms `doctor of dental surgery' and `doctor of 
        dental medicine' mean a doctor of dental surgery or of dental 
        medicine, as applicable, who is legally authorized to practice 
        dentistry by the State in which the doctor performs such 
        function and who is acting within the scope of the license of 
        the doctor when performing such functions.
            ``(3) The term `doctor of optometry' means a doctor of 
        optometry who is legally authorized to practice optometry by 
        the State in which the doctor so practices.''.
            (2) Conforming amendment.--Section 9831(c)(1) of the 
        Internal Revenue Code of 1986 is amended by striking ``The 
        requirements'' and inserting ``Subject to section 9826, the 
        requirements''.
            (3) Clerical amendment.--The table of sections for 
        subchapter B of chapter 100 of the Internal Revenue Code of 
        1986 is amended by adding at the end the following:

``Sec. 9826. Improving coverage under vision and dental plans.''.

SEC. 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.
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