2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-472l. - Participating dental provider contracts. Third-party access. Restrictions. Exceptions.

(a) For the purposes of this section:
(1) “Covered person” means a policyholder, subscriber, enrollee or other individual participating in a network dental benefit plan;
(2) “Dentist” means an individual licensed and registered as a dentist under chapter 379;
(3) “Dental office” means a dental office, or an office, laboratory or operation or consultation room in which dental medicine, dental surgery or dental hygiene is carried on as a portion of such office's, laboratory's or room's regular business, that is owned or operated by a dentist who, or a professional corporation organized and existing under chapter 594a for the purpose of rendering professional dental services that, is authorized to own or operate such office, laboratory or room under section 20-122;
(4) “Health carrier” has the same meaning as provided in section 38a-591a;
(5) “Intermediary” means a person authorized to negotiate and execute a health care provider contract with a health carrier on behalf of a dentist, dental office or network;
(6) “Network” means the group or groups of participating dental providers providing dental services under a network dental benefit plan;
(7) “Network dental benefit plan” means an insurance policy or contract, certificate or agreement offered, delivered, issued for delivery, renewed, amended or continued in this state to provide, deliver, arrange for, pay for or reimburse any of the costs of dental services that requires a covered person to use, or creates incentives, including, but not limited to, financial incentives, for a covered person to use, dentists or dental offices that are managed, owned, under contract with or employed by the health carrier or the health carrier's contractor or subcontractor;
(8) “Participating dental provider” means a dentist or dental office that, under a participating dental provider contract with a health carrier or the health carrier's contractor or subcontractor, agrees to provide dental services to the health carrier's covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles;
(9) “Participating dental provider contract” means a contract between a health carrier, or the health carrier's contractor or subcontractor, and a participating dental provider under which the participating dental provider agrees to provide dental services to the health carrier's covered persons, with an expectation of receiving payment or reimbursement directly or indirectly from the health carrier, other than coinsurance, copayments or deductibles; and
(10) “Third party” means a person that enters into a contract with a health carrier, or the health carrier's contractor or subcontractor, to gain access to the dental services or discounts provided under a participating dental provider contract, but does not mean an employer or other group for whom the health carrier, or the health carrier's contractor or subcontractor, provides administrative services.
(b) (1) Except as provided in subsection (c) of this section, no participating dental provider contract entered into, renewed or amended on or after January 1, 2022, between:
(A) A health carrier and an intermediary or a participating dental provider shall allow a third party to gain access to such participating dental provider contract, except the health carrier may permit a third party to gain access to such participating dental provider contract if, not later than thirty days after the contract permitting such third-party access is executed, renewed or amended or a later date mutually agreed to by the health carrier and such third party, the health carrier allows each participating dental provider that is a party to such participating dental provider contract to:
(i) Decline to participate in such third party's access to such participating dental provider contract, which declination shall not, in and of itself, constitute grounds for the health carrier to terminate or cancel such participating dental provider contract; or
(ii) Contract directly with such third party if such third party is a health carrier; or
(B) A participating dental provider or an intermediary and a health carrier, or the health carrier's contractor or subcontractor, shall permit the health carrier, or the health carrier's contractor or subcontractor, to enter into a contract with a third party that allows the third party to gain access to such participating dental provider contract unless:
(i) Such participating dental provider contract:
(I) Provides that the health carrier, or the health carrier's contractor or subcontractor, may enter into such contract with a third party and grant such access to a third party, and such third party may obtain the rights and responsibilities of such health carrier, or such health carrier's contractor or subcontractor, as if such third party were such health carrier, or such health carrier's contractor or subcontractor;
(II) Clearly identifies the provisions of such participating dental provider contract that allow the health carrier, or the health carrier's contractor or subcontractor, to grant such access to a third party; and
(III) Provides that a participating dental provider under such participating dental provider contract may decline to participate in such third party's access to such participating dental provider contract;
(ii) Such third party agrees to comply with all terms of such participating dental provider contract;
(iii) The health carrier, or the health carrier's contractor or subcontractor, discloses, in writing or by electronic means, to each participating dental provider under such participating dental provider contract the identity of such third party on the date that the health carrier, or the health carrier's contractor or subcontractor, enters into a contract with such third party to allow such third party to gain access to such participating dental provider contract;
(iv) The health carrier, or the health carrier's contractor or subcontractor:
(I) Makes a list containing the name of each third party that enters into a contract with such health carrier, or such health carrier's contractor or subcontractor, that allows such third party to gain access to such participating dental provider contract publicly available on such health carrier's, or such health carrier's contractor's or subcontractor's, Internet web site; and
(II) Updates the list required under subparagraph (B)(iv)(I) of this subdivision at least once every ninety days;
(v) The health carrier, or the health carrier's contractor or subcontractor, requires such third party to identify the source of any discount provided under such participating dental provider contract on each remittance advice or explanation of payment under which such third party takes such discount, except no such identification shall be required for an electronic transaction required under the Health Insurance Portability and Accountability Act of 1996, P.L. 104-191, as amended from time to time;
(vi) If the health carrier, or the health carrier's contractor or subcontractor, intends to terminate such participating dental provider contract, the health carrier, or the health carrier's contractor or subcontractor, sends a written notice to such third party disclosing such intended termination;
(vii) Such third party's right to a discounted rate under such participating dental provider contract ends on the termination date of such participating dental provider contract; and
(viii) The health carrier, or the health carrier's contractor or subcontractor, provides a copy of such participating dental provider contract to any participating dental provider under such participating dental provider contract not later than thirty days after such participating dental provider submits a request to the health carrier, or the health carrier's contractor or subcontractor, for such copy.
(2) No participating dental provider shall be required to provide dental services under a participating dental provider contract if a health carrier, or the health carrier's contractor or subcontractor, enters into a contract with a third party that allows the third party to gain access to the participating dental provider contract in violation of this section.
(3) No health carrier, and no health carrier's contractor or subcontractor, shall refuse to enter into a participating dental provider contract with a dentist or dental office because the dentist or dental office declines to participate in a third party's access to the participating dental provider contract.
(c) The requirements of subsection (b) of this section shall not apply to any contract that grants access to a participating dental provider contract:
(1) To a health carrier or other entity operating in accordance with the same brand licensee program as the health carrier, or the health carrier's contractor or subcontractor, that is a party to the participating dental provider contract;
(2) To an affiliate of the health carrier, or the health carrier's contractor or subcontractor, that is a party to the participating dental provider contract, provided such health carrier, or such health carrier's contractor or subcontractor, makes a list of such affiliates publicly available on such health carrier's, or such health carrier's contractor's or subcontractor's, Internet web site; or
(3) For dental services provided to beneficiaries in this state under the Medicaid program under Title XIX of the Social Security Act, as amended from time to time, or the Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act, as amended from time to time.
(P.A. 21-187, S. 2.)
History: P.A. 21-187 effective January 1, 2022.