2023 Idaho Code › Title 41 - INSURANCE › Chapter 18 - THE INSURANCE CONTRACT › Section 41-1849 - CONTRACTS WITH PROVIDERS OF DENTAL SERVICES.

41-1849. CONTRACTS WITH PROVIDERS OF DENTAL SERVICES. (1) No person contracting with dentists to provide coverage or reimbursement for dental services may require, as an element of any dental care provider participation contract, that the provider agree to adopt fees set by the person for dental care services that are not covered services under the contract. "Covered services" as used in this section means dental care services and procedures under the applicable dental plan, dental plan contract, or plan benefits for which payment is available to the covered person or dentist under the covered person’s plan or contract or for which payment to the covered person or to the dentist would be available but for the application of contractual limitations on reimbursement, such as deductibles, copayments, coinsurance, and waiting periods. All services or procedures are no longer covered services, and the plan can no longer impose, contractually or otherwise, a fee schedule or other limitation when the following criteria have been met:
(a) When the third-party payer is no longer liable for paying for an individual service or a procedure, in part or in whole, due to calendar-year limitations or benefit-year limitations; and
(b) A patient has received dental services and procedures that equal an additional one hundred percent (100%) of the amount of the patient’s capped annual maximum benefit for the calendar year or benefit year.
Once a patient’s capped annual maximum benefit amount for a calendar year or benefit year has been exceeded by one hundred percent (100%), a dentist may choose to provide dental services or procedures according to a plan’s fee schedule or to provide dental services or procedures at a fee agreed upon with the patient. The dentist must confer with and provide notice to the patient regarding the patient’s change in fee status, and any agreed-upon fee shall not exceed the lowest fee available to the dentist’s uninsured patients.
(2) A person contracting with dentists must provide one (1) or more methods of payment or reimbursement that:
(a) Provide the dentist one hundred percent (100%) of the contracted amount of the payment or reimbursement; and
(b) Do not require the dentist to incur a fee to access the payment or reimbursement.
(3) A person contracting with dentists may extend the provider network to other entities when:
(a) Full disclosure of the agreement has been provided to the dentist, including any variations in obligations and fee schedule from the original contract; and
(b) The dentist has been provided a timeframe of no less than two (2) weeks to decline participation.
This subsection shall not apply to a person operating in accordance with the same brand licensee program as the contracting person or to a person that is an affiliate, as long as the contractual terms, obligations, and fee schedule remain the same as the original agreement.
(4) Subsections (2) and (3) of this section shall apply to any contract with providers for dental services that is issued after December 31, 2021. Contracts that are in existence on December 31, 2021, shall be brought into compliance on the next anniversary date, the renewal date, or the expiration date of the applicable collective bargaining contract, if any, whichever date is latest.
History:
[41-1849, added 2010, ch. 126, sec. 1, p. 272; am. 2019, ch. 153, sec. 1, p. 505; am. 2021, ch. 184, sec. 1, p. 505.]