2023 Connecticut General Statutes › Title 38a - Insurance › Chapter 700c - Health Insurance › Section 38a-472h. - Fees charged by dentists, optometrists and ophthalmologists for noncovered benefits. Notice and posting required.

(a) No insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing:
(1) An individual or a group dental plan in this state shall include in any contract with a dentist licensed pursuant to chapter 379 that is entered into, renewed or amended on or after January 1, 2012, any provision that requires such dentist to accept as payment an amount set by such insurer, center, society, corporation or entity for services or procedures provided to an insured or enrollee that are not covered benefits under such insured's or enrollee's plan; or
(2) An individual or a group vision plan in this state shall include in any contract with an optometrist licensed pursuant to chapter 380 or an ophthalmologist licensed pursuant to chapter 370 that is entered into, renewed or amended on or after January 1, 2020, any provision that requires such optometrist or ophthalmologist to accept as payment an amount set by such insurer, center, society, corporation or entity for services, procedures or products provided to an insured or enrollee that are not covered benefits under such insured's or enrollee's plan.
(b) No dentist shall charge more for services or procedures that are not covered benefits than such dentist's usual and customary rate for such services or procedures, and no optometrist or ophthalmologist shall charge more for services, procedures or products that are not covered benefits than such optometrist's or ophthalmologist's usual and customary rate for such services, procedures or products.
(c) (1) Each evidence of coverage for an individual or a group dental plan shall include the following statement:
“IMPORTANT: If you opt to receive dental services or procedures that are not covered benefits under this plan, a participating dental provider may charge you his or her usual and customary rate for such services or procedures. Prior to providing you with dental services or procedures that are not covered benefits, the dental provider should provide you with a treatment plan that includes each anticipated service or procedure to be provided and the estimated cost of each such service or procedure. To fully understand your coverage, you may wish to review your evidence of coverage document.”
(2) Each evidence of coverage for an individual or a group vision plan shall include the following statement:
“IMPORTANT: If you opt to receive optometric or ophthalmologic services, procedures or products that are not covered benefits under this plan, a participating optometrist or ophthalmologist may charge you his or her usual and customary rate for such services, procedures or products. Prior to providing you with optometric or ophthalmologic services, procedures or products that are not covered benefits, the optometrist or ophthalmologist should provide you with a treatment plan that includes each anticipated service, procedure or product to be provided and the estimated cost of each such service, procedure or product. To fully understand your coverage, you may wish to review your evidence of coverage document.”
(d) Each dentist, optometrist and ophthalmologist shall post, in a conspicuous place, a notice stating that services, procedures or products, as applicable, that are not covered benefits under an insurance policy or plan might not be offered at a discounted rate.
(e) The provisions of this section shall not apply to:
(1) A self-insured plan that covers (A) dental services or procedures, or (B) optometric or ophthalmologic services, procedures or products;
(2) A contract that is incorporated in or derived from a collective bargaining agreement or in which some or all of the material terms are subject to a collective bargaining process;
(3) A contract that is derived from a multiemployer plan, as defined in Section 3 of the Employee Retirement Income Security Act of 1974, as amended from time to time; or
(4) A network of ophthalmologists or optometrists, or both, when servicing a plan or contract described in subdivision (1), (2) or (3) of this subsection.
(P.A. 11-58, S. 19; P.A. 12-145, S. 9; P.A. 15-122, S. 1; P.A. 19-201, S. 1.)
History: P.A. 11-58 effective January 1, 2012; P.A. 12-145 made a technical change in Subsec. (a), effective June 15, 2012; P.A. 15-122 amended Subsec. (a) by designating existing provision re prohibition on dental plans for noncovered benefits as Subdiv. (1) and adding Subdiv. (2) re prohibition on vision plans for noncovered benefits, amended Subsec. (b) by adding references to optometrist and making a technical change, amended Subsec. (c) by designating existing provisions re inclusion of statement in evidence of coverage re noncovered dental services or procedures as Subdiv. (1) and adding Subdiv. (2) re inclusion of statement in evidence of coverage re noncovered optometric services or procedures, amended Subsec. (d) to add reference to optometrist, and amended Subsec. (e) to add reference to optometric services, effective January 1, 2016; P.A. 19-201 added provisions re ophthalmologists and products in Subsecs. (a)(2), (b), (c)(2), (d) and (e)(1), amended Subsec. (a)(2) by substituting “2020” for “2016”, amended Subsec. (e) by adding Subdiv. (3) re multiemployer plans and adding Subdiv. (4) re networks of ophthalmologists or optometrists, and made technical changes, effective January 1, 2020.
See Sec. 20-138b re health care center or preferred provider network offering ophthalmologic care and optometric care.
See Sec. 20-138d re coverage for services of optometrists.