Introduced Version
HOUSE BILL No. 1351
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 27-7-18; IC 27-8-11-14.
Synopsis: Dental matters. Provides that if an insured assigns the
insured's rights to benefits for dental services to the provider of the
dental services, the insurer shall pay the benefits assigned by the
insured to the provider of the dental services. 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 dental provider network contract is entered into, renewed, or
materially modified, any provider that is a party to the 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 dental provider that chooses not
to 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.
Effective: July 1, 2024.
Zent, Snow, Fleming
January 10, 2024, read first time and referred to Committee on Insurance.
2024 IN 1351—LS 7008/DI 55 Introduced
Second Regular Session of the 123rd General Assembly (2024)
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
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between statutes enacted by the 2023 Regular Session of the General Assembly.
HOUSE BILL No. 1351
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 27-7-18 IS ADDED TO THE INDIANA CODE AS
2 A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY
3 1, 2024]:
4 Chapter 18. Third Party Access to Dental Provider Networks
5 Sec. 1. As used in this chapter, "contracting entity" means a
6 dental carrier, a third party administrator, or another person that
7 enters into a provider network contract with providers for the
8 delivery of dental services in the ordinary course of business.
9 Sec. 2. As used in this chapter, "covered individual" means an
10 individual who is entitled to:
11 (1) dental services; or
12 (2) coverage of dental services;
13 through a provider network contract.
14 Sec. 3. As used in this chapter, "dental carrier" means any of
15 the following:
16 (1) An insurer that issues a policy of accident and sickness
17 insurance that covers dental services.
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1 (2) A health maintenance organization that provides, or
2 provides coverage for, dental services.
3 (3) An entity that:
4 (A) provides dental services; or
5 (B) arranges for dental services to be provided;
6 but is not itself a provider.
7 Sec. 4. (a) As used in this chapter, "dental service" means any
8 service provided by a dentist within the scope of the dentist's
9 licensure under IC 25-14.
10 (b) The term does not include a service delivered by a provider
11 that is billed as a medical expense.
12 Sec. 5. As used in this chapter, "health insurer" means:
13 (1) an insurer that issues policies of accident and sickness
14 insurance (as defined in IC 27-8-5-1); or
15 (2) a health maintenance organization (as defined in
16 IC 27-13-1-19).
17 Sec. 6. As used in this chapter, "person" means an individual, a
18 corporation, a limited liability company, a partnership, or any
19 other legal entity.
20 Sec. 7. (a) As used in this chapter, "provider" means:
21 (1) a dentist licensed under IC 25-14; or
22 (2) a dental office through which one (1) or more dentists
23 licensed under IC 25-14 provide dental services.
24 (b) The term does not include a physician organization or
25 physician hospital organization that leases or rents the network of
26 the physician organization or physician hospital organization
27 network to a third party.
28 Sec. 8. As used in this chapter, "provider network contract"
29 means a contract between a contracting entity and one (1) or more
30 providers:
31 (1) that establishes a network through which the providers:
32 (A) provide dental services to covered individuals; and
33 (B) are compensated for providing the dental services; and
34 (2) that specifies the rights and responsibilities of the
35 contracting entity and the providers concerning the network.
36 Sec. 9. (a) As used in this chapter, "third party" means a person
37 that enters into a contract with a contracting entity or another
38 third party to gain access to:
39 (1) a provider network contract;
40 (2) dental services provided pursuant to a provider network
41 contract; or
42 (3) contractual discounts provided pursuant to a provider
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1 network contract.
2 (b) The term does not include an employer or another group or
3 entity for which the contracting entity provides administrative
4 services.
5 Sec. 10. (a) This section applies if a contracting entity seeks to
6 grant a third party access to:
7 (1) a provider network contract;
8 (2) dental services provided pursuant to a provider network
9 contract; or
10 (3) contractual discounts provided pursuant to a provider
11 network contract.
12 (b) Except as provided in subsection (c) and section 16 of this
13 chapter, in order for a contracting entity to grant a third party
14 access as described in subsection (a), the following conditions must
15 be satisfied:
16 (1) When a provider network contract is entered into or
17 renewed, or when there are material modifications to a
18 provider network contract relevant to granting access to a
19 third party as described in subsection (a):
20 (A) any provider that is a party to the provider network
21 contract must be allowed to choose not to participate in the
22 third party access as described in subsection (a); or
23 (B) if third party access is to be provided through the
24 acquisition of the provider network by a health insurer,
25 any provider that is a party to the provider network
26 contract must be allowed to enter into a contract directly
27 with the health insurer that acquired the provider
28 network.
29 (2) The provider network contract must specifically authorize
30 the contracting entity to enter into an agreement with third
31 parties allowing the third parties to obtain the contracting
32 entity's rights and responsibilities as if the third party were
33 the contracting entity.
34 (3) If the contracting entity seeking to grant a third party
35 access as described in subsection (a) is a dental carrier, a
36 provider that is a party to the provider network contract must
37 have chosen to participate in third party access at the time the
38 provider network contract was entered into or renewed.
39 (4) If the contracting entity seeking to grant a third party
40 access as described in subsection (a) is a health insurer, the
41 provider network contract must contain a third party access
42 provision specifically granting third party access to the
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1 provider network.
2 (5) If the contracting entity seeking to grant a third party
3 access as described in subsection (a) is a dental carrier, the
4 provider network contract must state that the provider has a
5 right to choose not to participate in the third party access.
6 (6) The third party being granted access as described in
7 subsection (a) must agree to comply with all of the terms of
8 the provider network contract.
9 (7) The contracting entity seeking to grant third party access
10 as described in subsection (a) must identify to each provider
11 that is a party to the provider network contract, in writing or
12 electronic form, all third parties in existence as of the date on
13 which the provider network contract is entered into or
14 renewed.
15 (8) The contracting entity granting third party access as
16 described in subsection (a) must identify, in a list on its
17 website that is updated at least once every ninety (90) days, all
18 third parties to which third party access has been granted.
19 (9) If third party access as described in subsection (a) is to be
20 granted through the sale or leasing of the network established
21 by the provider network contract, the contracting entity must
22 notify all providers that are parties to the provider network
23 contract of the leasing or sale of the network at least thirty
24 (30) days before the sale or lease of the network takes effect.
25 (10) The contracting entity seeking to grant third party access
26 to contractual discounts as described in subsection (a)(3) must
27 require each third party to identify the source of the discount
28 on all remittance advices or explanations of payment under
29 which a discount is taken. However, this subdivision does not
30 apply to electronic transactions mandated by the federal
31 Health Insurance Portability and Accountability Act of 1996
32 (Public Law 104-191).
33 (c) A contracting entity may grant a third party access as
34 described in subsection (a) even if the conditions set forth in
35 subsection (b)(1) are not satisfied if the contracting entity is not a
36 health insurer or a dental carrier.
37 (d) Except as provided in subsection (c) and section 16 of this
38 chapter, a provider that is a party to a provider network contract
39 is not required to provide dental services pursuant to third party
40 access granted as described in subsection (a) unless all of the
41 applicable conditions set forth in subsection (b) are satisfied.
42 Sec. 11. A contracting entity that is a party to a provider
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1 network contract with a provider that chooses under section
2 10(b)(1)(A) of this chapter not to participate in third party access
3 shall not alter the provider's rights or status under the provider
4 network contract because of the provider's choice not to
5 participate in third party access.
6 Sec. 12. A contracting entity that is a party to a provider
7 network contract shall notify a third party granted third party
8 access as described in section 10(a) of this chapter of the
9 termination of the provider network contract not more than thirty
10 (30) days after the date of the termination.
11 Sec. 13. The right of a third party to contractual discounts
12 described in section 10(a)(3) of this chapter ceases as of the
13 termination date of the provider network contract.
14 Sec. 14. A contracting entity that is a party to a provider
15 network contract shall make a copy of the provider network
16 contract relied on in the adjudication of a claim available to a
17 participating provider not more than thirty (30) days after the date
18 of the participating provider's request.
19 Sec. 15. When entering into a provider network contract with
20 providers, a contracting entity shall not reject a provider as a
21 party to the provider network contract because the provider
22 chooses or has chosen under section 10(b)(1)(A) of this chapter not
23 to participate in third party access.
24 Sec. 16. (a) Section 10 of this chapter does not apply to access as
25 described in section 10(a) of this chapter if granted by a
26 contracting entity to:
27 (1) a dental carrier or other entity operating in accordance
28 with the same brand licensee program as the contracting
29 entity; or
30 (2) an entity that is an affiliate of the contracting entity.
31 (b) For the purposes of this section, a contracting entity shall
32 make a list of the contracting entity's affiliates available to
33 providers on the contracting entity's website.
34 (c) Section 10 of this chapter does not apply to a provider
35 network contract established for the purpose of providing dental
36 services to beneficiaries of health programs sponsored by the state,
37 including Medicaid (IC 12-15) and the children's health insurance
38 program (IC 12-17.6).
39 Sec. 17. The provisions of this chapter cannot be waived by
40 contract. A contract provision that:
41 (1) conflicts with this chapter; or
42 (2) purports to waive any requirements of this chapter;
2024 IN 1351—LS 7008/DI 55 6
1 is null and void.
2 Sec. 18. (a) If a person violates this chapter, the insurance
3 commissioner may enter an order requiring the person to cease
4 and desist from violating this chapter.
5 (b) If a person violates a cease and desist order issued under
6 subsection (a), the insurance commissioner, after notice and
7 hearing under IC 4-21.5, may:
8 (1) impose a civil penalty upon the person of not more than
9 ten thousand dollars ($10,000) for each day of violation;
10 (2) suspend or revoke the person's certificate of authority, if
11 the person holds a certificate of authority under this title; or
12 (3) both impose a civil penalty upon the person under
13 subdivision (1) and suspend or revoke the person's certificate
14 of authority under subdivision (2).
15 SECTION 2. IC 27-8-11-14 IS ADDED TO THE INDIANA CODE
16 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
17 1, 2024]: Sec. 14. (a) As used in this section, "dental services"
18 means health care services provided by:
19 (1) a dentist licensed under IC 25-14;
20 (2) an individual using a dental residency permit issued under
21 IC 25-14-1-5;
22 (3) an individual who holds:
23 (A) a dental faculty license under IC 25-14-1-5.5; or
24 (B) an instructor's license under IC 25-14-1-27.5;
25 (4) a dental hygienist licensed under IC 25-13; or
26 (5) a dental assistant, as defined in IC 25-14-1-1.5(4).
27 (b) If an insured assigns the rights of the insured to benefits for
28 dental services to the provider of the dental services, the insurer
29 shall pay the benefits assigned by the insured to the provider of the
30 dental services.
31 (c) An insurer shall make a payment under this section:
32 (1) directly to the provider of the dental services; and
33 (2) according to the same criteria and payment schedule
34 under which the insurer would have been required to make
35 the payment to the insured if the insured had not assigned the
36 insured's rights to the benefits.
37 (d) An assignment of benefits under this section does not affect
38 or limit the insurer's obligation to pay the benefits.
39 (e) An insurer's payment of benefits in compliance with this
40 section discharges the insurer's obligation to pay the benefits to the
41 insured.
2024 IN 1351—LS 7008/DI 55