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SB 5351 - Dental insurance practices

Source

Section 1

  1. A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may not deny coverage for procedures solely on the basis that the procedures were performed on the same day.

  2. Nothing in this section shall prevent a dental only plan offered by a carrier or limited health care service contractor from denying a claim for coverage where such denial relates in whole or in part to any of the following:

    1. Limitations intended to prevent fraud, waste, and abuse;

    2. A claim indicating unbundling of procedure elements where payment for a service bundles multiple procedure elements;

    3. Clinical appropriateness;

    4. Medical necessity;

    5. A final benefit decision that has been pended due to the need for further documentation or provider narrative; or

    6. Plan benefit limitations.

Section 2

  1. A dental only plan offered by a carrier or limited health care service contractor, as defined in RCW 48.44.035, may pay a claim for reimbursement made by a dental care provider using a credit card if:

    1. The carrier or limited health care service contractor notifies the provider, in advance, of any fees associated with the use of the credit card;

    2. The carrier or limited health care service contractor offers the provider an alternative payment method that does not impose fees or similar charges on the provider; and

    3. The carrier or limited health care service contractor advises the provider of available methods of payment and provides clear instructions to the provider as to how to select an alternative payment method.

  2. If a carrier or limited health care service contractor contracts with a vendor to process payments of dental providers' claims, the carrier or limited health care service contractor shall require the vendor to comply with the provisions of subsection (1)(a) of this section.

Section 3

The insurance commissioner may adopt any rules necessary to implement sections 1 and 2 of this act.

Section 4

  1. The office of the insurance commissioner shall enter into a contract with the William D. Ruckelshaus center to:

    1. Design, convene, and facilitate a collaborative forum with participation from:

      1. The Washington state dental association;

      2. A representative of the Washington denturist association;

      3. Dental insurance carriers, including those carriers with a significant commercial market share in Washington state;

      4. Consumer representatives;

    2. The office of the insurance commissioner; and

    1. Other relevant interested organizations as appropriate;

    1. Facilitate discussions to address issues related to:

      1. Dental loss ratio; and

      2. Relative payment for dentists or denturists based upon their provider network status including, but not limited to, payment based on the usual and customary rate; and

    2. Develop recommendations for legislative or regulatory action.

  2. The William D. Ruckelshaus center shall:

    1. Provide quarterly progress updates to legislative members designated by the chairs of the appropriate legislative committees; and

    2. Submit a final report, summarizing findings, areas of agreement, and recommendations for legislative or regulatory action, to the legislature by June 30, 2026.

Section 5

  1. Each health carrier offering a dental only plan shall submit to the commissioner on or before April 1st of each year as part of the additional data statement or as a supplemental data statement the following information for the preceding year that is derived from the carrier's annual statement, including the exhibit of premiums, enrollments, and utilization for the company at an aggregate level and the additional data to the annual statement, which must be based on Washington data and may not include data from other states:

    1. The total number of dental members;

    2. The total amount of dental revenue;

    3. The total amount of dental payments;

    4. The dental loss ratio that is computed by dividing the total amount of dental payments by the total amount of dental revenues;

    5. The average amount of premiums per member per month; and

    6. The percentage change in the average premium per member per month, measured from the previous year.

  2. A carrier shall electronically submit the information described in subsection (1) of this section in a format and according to instructions prescribed by the commissioner.

  3. The commissioner shall make the information reported under this section available to the public in a format that allows comparison among carriers through a searchable public website on the internet.

  4. For the purposes of licensed disability insurers and health care service contractors, the commissioner shall work collaboratively with insurers to develop an additional or supplemental data statement that utilizes to the maximum extent possible information from the annual statement forms that are currently filed by these entities.

  5. For purposes of this section, "health carrier," in addition to the definition in RCW 48.43.005, also includes health care service contractors, limited health care service contractors, and disability insurers offering dental only coverage.

  6. Nothing in this section is intended to establish a minimum dental loss ratio.

Section 6

Section 4 of this act is necessary for the immediate preservation of the public peace, health, or safety, or support of the state government and its existing public institutions, and takes effect July 1, 2025.

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