Introduced Version
SENATE BILL No. 136
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 27-7.
Synopsis: Dental plans and access to dental networks. Prohibits a
dental plan (an insurance policy, a health maintenance organization
contract, or a preferred provider plan) from directly or indirectly
requiring a dental provider to provide a dental service to a covered
individual at a fee amount that is: (1) set by the dental plan; or (2)
subject to the approval of the dental plan; unless the dental service is
a covered service under the dental plan. Provides that a dental plan
violates this prohibition by requiring a dental provider to provide a
dental service to a covered individual at a fee amount set by the dental
plan or subject to the dental plan's approval even if the dental service
is a covered service if the coverage of the dental service is merely
nominal or de minimis coverage. Prohibits a third party administrator
or another person from arranging for a dental provider to provide dental
services for a dental plan that sets the amount of the fee for any dental
services unless the dental services are covered services under the
dental plan. Provides that a contracting entity (a dental carrier, a third
party administrator, or another person that enters into a provider
network contract with providers of dental services) may not grant a
third party access to the provider network contract or to dental services
or contractual discounts provided pursuant to the provider network
contract unless certain conditions are satisfied. Provides that when a
provider network contract is entered into or renewed, or when there are
material modifications to a provider network contract, any dental
service provider that is a party to the provider network contract must
be allowed to choose not to participate in the third party access.
Prohibits a contracting entity from: (1) altering the rights or status
under a provider network contract of a provider that chooses not to
(Continued next page)
Effective: July 1, 2022.
Zay
January 4, 2022, read first time and referred to Committee on Insurance and Financial
Institutions.
2022 IN 136—LS 6590/DI 55 Digest Continued
participate in third party access; or (2) rejecting a provider as a party
to a provider network contract because the provider chose not to
participate in third party access. Authorizes the insurance
commissioner to issue a cease and desist order against a person that
violates any of these prohibitions and, if the person violates the cease
and desist order, to impose a civil penalty upon the person and suspend
or revoke the person's certificate of authority.
2022 IN 136—LS 6590/DI 552022 IN 136—LS 6590/DI 55 Introduced
Second Regular Session of the 122nd General Assembly (2022)
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
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Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
between statutes enacted by the 2021 Regular Session of the General Assembly.
SENATE BILL No. 136
A BILL FOR AN ACT to amend the Indiana Code concerning
insurance.
Be it enacted by the General Assembly of the State of Indiana:
1 SECTION 1. IC 27-7-17 IS ADDED TO THE INDIANA CODE AS
2 A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY
3 1, 2022]:
4 Chapter 17. Dental Plans Setting Fees for Dental Services
5 Sec. 1. As used in this chapter, "covered individual" means an
6 individual who is entitled to:
7 (1) dental services; or
8 (2) coverage of dental services.
9 Sec. 2. As used in this chapter, "covered service" means a dental
10 service for which a reimbursement:
11 (1) is available under a dental plan; or
12 (2) would be available under a dental plan but for the
13 application of contractual limitations such as:
14 (A) deductibles;
15 (B) copayments;
16 (C) coinsurance;
17 (D) waiting periods;
2022 IN 136—LS 6590/DI 55 2
1 (E) annual or lifetime maximums;
2 (F) frequency limitations;
3 (G) alternative benefit payments; or
4 (H) any other limitation;
5 under the dental plan.
6 Sec. 3. (a) As used in this chapter, "dental plan" means any of
7 the following:
8 (1) A policy issued by an insurer (as defined in IC 27-1-2-3(x))
9 that provides coverage for dental services.
10 (2) A contract under which a health maintenance organization
11 (as defined in IC 27-13-1-19) provides or covers dental
12 services.
13 (3) A preferred provider plan (as defined in IC 27-8-11-1(g))
14 that provides or covers dental services.
15 (b) The term does not include the following:
16 (1) A policy providing comprehensive coverage described in
17 Class 1(b) and Class 2(a) of IC 27-1-5-1.
18 (2) Accident only, Medicare supplement, long term care, or
19 disability income insurance.
20 (3) Coverage issued as a supplement to liability insurance.
21 (4) Automobile medical payment insurance.
22 (5) A specified disease policy.
23 (6) Worker's compensation or similar insurance.
24 (7) A student health plan.
25 (8) A supplemental plan that always pays in addition to other
26 coverage.
27 Sec. 4. As used in this chapter, "dental service" means any
28 service provided by a dentist within the scope of the dentist's
29 licensure under IC 25-14.
30 Sec. 5. As used in this chapter, "person" means an individual, a
31 corporation, a limited liability company, a partnership, or any
32 other legal entity.
33 Sec. 6. As used in this chapter, "provider" means:
34 (1) a dentist licensed under IC 25-14; or
35 (2) a dental office through which one (1) or more dentists
36 licensed under IC 25-14 provide dental services.
37 Sec. 7. (a) A dental plan may not directly or indirectly require
38 a provider to provide a dental service to a covered individual at a
39 fee amount that is:
40 (1) set by the dental plan; or
41 (2) subject to the approval of the dental plan;
42 unless the dental service is a covered service.
2022 IN 136—LS 6590/DI 55 3
1 (b) A dental plan that requires a provider to provide a dental
2 service to a covered individual at a fee amount that is:
3 (1) set by the dental plan; or
4 (2) subject to the approval of the dental plan;
5 violates subsection (a) even if the dental service is a covered service
6 if the coverage of the dental service under the dental plan is merely
7 nominal or de minimis coverage. The coverage of a dental service
8 under a dental plan is merely nominal or de minimis for the
9 purposes of this subsection unless the coverage compensates the
10 provider for the dental service in an amount of at least fifty percent
11 (50%) of the provider's prevailing fee for the dental service.
12 Sec. 8. A third party administrator or other person that:
13 (1) is not a dental plan; but
14 (2) arranges for providers to provide dental services through
15 dental plans or through another sort of network
16 arrangement;
17 shall not arrange for a provider to provide dental services for a
18 dental plan that sets the amount of the fee for the dental services
19 unless the dental services are covered services under the dental
20 plan.
21 Sec. 9. (a) If:
22 (1) an insurer (as defined in IC 27-1-2-3(x));
23 (2) a health maintenance organization (as defined in
24 IC 27-13-1-19);
25 (3) a preferred provider plan (as defined in IC 27-8-11-1(g));
26 or
27 (4) any other person;
28 violates this chapter, the insurance commissioner may enter an
29 order requiring the person to cease and desist from violating this
30 chapter.
31 (b) If a person violates a cease and desist order issued under
32 subsection (a), the insurance commissioner, after notice and
33 hearing under IC 4-21.5, may:
34 (1) impose a civil penalty upon the person of not more than
35 ten thousand dollars ($10,000) for each day of violation;
36 (2) suspend or revoke the person's certificate of authority, if
37 the person holds a certificate of authority under this title; or
38 (3) both impose a civil penalty upon the person under
39 subdivision (1) and suspend or revoke the person's certificate
40 of authority under subdivision (2).
41 SECTION 2. IC 27-7-18 IS ADDED TO THE INDIANA CODE AS
42 A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY
2022 IN 136—LS 6590/DI 55 4
1 1, 2022]:
2 Chapter 18. Third Party Access to Dental Provider Networks
3 Sec. 1. As used in this chapter, "contracting entity" means a
4 dental carrier, a third party administrator, or another person that
5 enters into a provider network contract with providers for the
6 delivery of dental services in the ordinary course of business.
7 Sec. 2. As used in this chapter, "covered individual" means an
8 individual who is entitled to:
9 (1) dental services; or
10 (2) coverage of dental services;
11 through a provider network contract.
12 Sec. 3. As used in this chapter, "dental carrier" means any of
13 the following:
14 (1) An insurer that issues a policy of accident and sickness
15 insurance that covers dental services.
16 (2) A health maintenance organization that provides, or
17 provides coverage for, dental services.
18 (3) An entity that:
19 (A) provides dental services; or
20 (B) arranges for dental services to be provided;
21 but is not itself a provider.
22 Sec. 4. (a) As used in this chapter, "dental service" means any
23 service provided by a dentist within the scope of the dentist's
24 licensure under IC 25-14.
25 (b) The term does not include a service delivered by a provider
26 that is billed as a medical expense.
27 Sec. 5. As used in this chapter, "health insurer" means:
28 (1) an insurer that issues policies of accident and sickness
29 insurance (as defined in IC 27-8-5-1); or
30 (2) a health maintenance organization (as defined in
31 IC 27-13-1-19).
32 Sec. 6. As used in this chapter, "person" means an individual, a
33 corporation, a limited liability company, a partnership, or any
34 other legal entity.
35 Sec. 7. (a) As used in this chapter, "provider" means:
36 (1) a dentist licensed under IC 25-14; or
37 (2) a dental office through which one (1) or more dentists
38 licensed under IC 25-14 provide dental services.
39 (b) The term does not include a physician organization or
40 physician hospital organization that leases or rents the network of
41 the physician organization or physician hospital organization
42 network to a third party.
2022 IN 136—LS 6590/DI 55 5
1 Sec. 8. As used in this chapter, "provider network contract"
2 means a contract between a contracting entity and one (1) or more
3 providers:
4 (1) that establishes a network through which the providers:
5 (A) provide dental services to covered individuals; and
6 (B) are compensated for providing the dental services; and
7 (2) that specifies the rights and responsibilities of the
8 contracting entity and the providers concerning the network.
9 Sec. 9. (a) As used in this chapter, "third party" means a person
10 that enters into a contract with a contracting entity or another
11 third party to gain access to:
12 (1) a provider network contract;
13 (2) dental services provided pursuant to a provider network
14 contract; or
15 (3) contractual discounts provided pursuant to a provider
16 network contract.
17 (b) The term does not include an employer or another group or
18 entity for which the contracting entity provides administrative
19 services.
20 Sec. 10. (a) This section applies if a contracting entity seeks to
21 grant a third party access to:
22 (1) a provider network contract;
23 (2) dental services provided pursuant to a provider network
24 contract; or
25 (3) contractual discounts provided pursuant to a provider
26 network contract.
27 (b) Except as provided in subsection (c) and section 16 of this
28 chapter, in order for a contracting entity to grant a third party
29 access as described in subsection (a), the following conditions must
30 be satisfied:
31 (1) When a provider network contract is entered into or
32 renewed, or when there are material modifications to a
33 provider network contract relevant to granting access to a
34 third party as described in subsection (a):
35 (A) any provider that is a party to the provider network
36 contract must be allowed to choose not to participate in the
37 third party access as described in subsection (a); or
38 (B) if third party access is to be provided through the
39 acquisition of the provider network by a health insurer,
40 any provider that is a party to the provider network
41 contract must be allowed to enter into a contract directly
42 with the health insurer that acquired the provider
2022 IN 136—LS 6590/DI 55 6
1 network.
2 (2) The provider network contract must specifically authorize
3 the contracting entity to enter into an agreement with third
4 parties allowing the third parties to obtain the contracting
5 entity's rights and responsibilities as if the third party were
6 the contracting entity.
7 (3) If the contracting entity seeking to grant a third party
8 access as described in subsection (a) is a dental carrier, a
9 provider that is a party to the provider network contract must
10 have chosen to participate in third party access at the time the
11 provider network contract was entered into or renewed.
12 (4) If the contracting entity seeking to grant a third party
13 access as described in subsection (a) is a health insurer, the
14 provider network contract must contain a third party access
15 provision specifically granting third party access to the
16 provider network.
17 (5) If the contracting entity seeking to grant a third party
18 access as described in subsection (a) is a dental carrier, the
19 provider network contract must state that the provider has a
20 right to choose not to participate in the third party access.
21 (6) The third party being granted access as described in
22 subsection (a) must agree to comply with all of the terms of
23 the provider network contract.
24 (7) The contracting entity seeking to grant third party access
25 as described in subsection (a) must identify to each provider
26 that is a party to the provider network contract, in writing or
27 electronic form, all third parties in existence as of the date on
28 which the provider network contract is entered into or
29 renewed.
30 (8) The contracting entity granting third party access as
31 described in subsection (a) must identify, in a list on its
32 Internet web site that is updated at least once every ninety
33 (90) days, all third parties to which third party access has
34 been granted.
35 (9) If third party access as described in subsection (a) is to be
36 granted through the sale or leasing of the network established
37 by the provider network contract, the contracting entity must
38 notify all providers that are parties to the provider network
39 contract of the leasing or sale of the network at least thirty
40 (30) days before the sale or lease of the network takes effect.
41 (10) The contracting entity seeking to grant third party access
42 to contractual discounts as described in subsection (a)(3) must
2022 IN 136—LS 6590/DI 55 7
1 require each third party to identify the source of the discount
2 on all remittance advices or explanations of payment under
3 which a discount is taken. However, this subdivision does not
4 apply to electronic transactions mandated by the federal
5 Health Insurance Portability and Accountability Act of 1996
6 (Public Law 104-191).
7 (c) A contracting entity may grant a third party access as
8 described in subsection (a) even if the conditions set forth in
9 subsection (b)(1) are not satisfied if the contracting entity is not a
10 health insurer or a dental carrier.
11 (d) Except as provided in subsection (c) and section 16 of this
12 chapter, a provider that is a party to a provider network contract
13 is not required to provide dental services pursuant to third party
14 access granted as described in subsection (a) unless all of the
15 applicable conditions set forth in subsection (b) are satisfied.
16 Sec. 11. A contracting entity that is a party to a provider
17 network contract with a provider that chooses under section
18 10(b)(1)(A) of this chapter not to participate in third party access
19 shall not alter the provider's rights or status under the provider
20 network contract because of the provider's choice not to
21 participate in third party access.
22 Sec. 12. A contracting entity that is a party to a provider
23 network contract shall notify a third party granted third party
24 access as described in section 10(a) of this chapter of the
25 termination of the provider network contract not more than thirty
26 (30) days after the date of the termination.
27 Sec. 13. The right of a third party to contractual discounts
28 described in section 10(a)(3) of this chapter ceases as of the
29 termination date of the provider network contract.
30 Sec. 14. A contracting entity that is a party to a provider
31 network contract shall make a copy of the provider network
32 contract relied on in the adjudication of a claim available to a
33 participating provider not more than thirty (30) days after the date
34 of the participating provider's request.
35 Sec. 15. When entering into a provider network contract with
36 providers, a contracting entity shall not reject a provider as a
37 party to the provider network contract because the provider
38 chooses or has chosen under section 10(b)(1)(A) of this chapter not
39 to participate in third party access.
40 Sec. 16. (a) Section 10 of this chapter does not apply to access as
41 described in section 10(a) of this chapter if granted by a
42 contracting entity to:
2022 IN 136—LS 6590/DI 55 8
1 (1) a dental carrier or other entity operating in accordance
2 with the same brand licensee program as the contracting
3 entity; or
4 (2) an entity that is an affiliate of the contracting entity.
5 (b) For the purposes of this section, a contracting entity shall
6 make a list of the contracting entity's affiliates available to
7 providers on the contracting entity's Internet web site.
8 (c) Section 10 of this chapter does not apply to a provider
9 network contract established for the purpose of providing dental
10 services to beneficiaries of health programs sponsored by the state,
11 including Medicaid (IC 12-15) and the children's health insurance
12 program (IC 12-17.6).
13 Sec. 17. The provisions of this chapter cannot be waived by
14 contract. A contract provision that:
15 (1) conflicts with this chapter; or
16 (2) purports to waive any requirements of this chapter;
17 is null and void.
18 Sec. 18. (a) If a person violates this chapter, the insurance
19 commissioner may enter an order requiring the person to cease
20 and desist from violating this chapter.
21 (b) If a person violates a cease and desist order issued under
22 subsection (a), the insurance commissioner, after notice and
23 hearing under IC 4-21.5, may:
24 (1) impose a civil penalty upon the person of not more than
25 ten thousand dollars ($10,000) for each day of violation;
26 (2) suspend or revoke the person's certificate of authority, if
27 the person holds a certificate of authority under this title; or
28 (3) both impose a civil penalty upon the person under
29 subdivision (1) and suspend or revoke the person's certificate
30 of authority under subdivision (2).
2022 IN 136—LS 6590/DI 55