Oct 03, 2024
California - AB 1048 Includes New Dental Coverage Requirements and Reporting Obligations
In 2023, Governor Newsom signed the latest CDA-sponsored bill strengthening dental plan coverage requirements and transparency. AB 1048 will take effect January. 1, 2025 and, among other things, will prohibit dental benefit plans from denying claims related to a patient’s preexisting dental conditions and prohibit plans in the large group market from imposing arbitrary waiting periods before patients can access their full benefits.
Digital Democracy – CalMatters - AB 1048 – Dental Benefits and Rate Review
On and after January 1, 2025, this bill would prohibit a health care service plan or health insurer that covers dental services, including a specialized health care service plan or health insurer that covers dental services, from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or preexisting condition provision, as specified. This bill applies to fully insured large group dental plans. Because a violation of these requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.
This bill would include health care service plan contracts and health insurance policies covering dental services, including specialized health care service plan contracts and specialized health insurance policies covering dental services, within those provisions. The bill would retain the exclusion with respect to specialized health care service plan contracts and specialized health insurance policies that do not provide dental services. By making plan contracts covering dental services, including specialized health care service plan contracts that provide dental services subject to these rate review provisions, the bill would expand the scope of a crime, thereby imposing a state-mandated local program.
California Health Benefits Review Program – Abbreviated Analysis
Bill Language
AB 1048 prohibits a health insurer that covers dental services or specialized health care service plan or health insurer that covers dental services, from issuing, amending, renewing, or offering a plan contract or policy that imposes a dental waiting period provision or pre-existing condition provision, upon an enrollee or insured. The bill language exempts Medi-Cal dental managed care contracts authorized under Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
The bill would establish the following definitions:
- “Dental waiting period provision” means a contract provision that limits coverage for a specified period of time following an enrollee’s effective date of coverage.
- “Health care service plan” means a health care service plan that issues, sells, renews, or offers a plan contract covering dental services or a specialized health care service plans covering dental services.
- “Preexisting condition provision” means a contract provision that excludes coverage for charges or expenses incurred during a specified period following an enrollee’s effective date of coverage, as to a condition for which dental advice, diagnosis, care or treatment was recommended or received during a specified period immediately preceding the effective date of coverage.
- The bill would also require the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to establish the appropriate methodology, factors, and assumptions to determine whether a rate change for a specialized health care service plan contract or specialized health insurance policy covering dental services is unreasonable, or not justified, under the applicable requirements of the rate review provisions under existing law.
Governor signs second CDA- sponsored dental plan reform bill – California Dental Association
While every effort has been taken in compiling this information to ensure that its contents are totally accurate, neither the publisher nor the author can accept liability for any inaccuracies or changed circumstances of any information herein or for the consequences of any reliance placed upon it. This publication is distributed on the understanding that the publisher is not engaged in rendering legal, accounting, or other professional advice or services. Readers should always seek professional advice before entering into any commitments.
