Bill Summary
The Dental and Optometric Care Access Act of 2019 is a bill that aims to improve healthcare coverage for vision and dental care. It amends title XXVII of the Public Health Service Act to implement changes in the coverage of these services. Under this act, a doctor of optometry, doctor of dental surgery, or doctor of dental medicine who participates in a group health plan or individual/group health insurance coverage can charge enrollees for items or services that are not covered by the plan or coverage, as long as the amount charged is equal to or less than their usual and customary rate for non-enrollees. This applies only to items or services that the plan is required to pay for, not minor or nominal services. The agreement between the doctor and the plan can be extended for longer than 2 years only if the doctor agrees, and there are no restrictions on the doctor's choice of laboratories or suppliers. The act also allows individuals to bring legal action against plans that violate these requirements and provides a private right of action with a maximum monetary penalty of $1,000 per day. Plans can choose to be excluded from these requirements, but not for the duration of their limited scope vision and dental plans. The act also includes definitions for key terms and states that state law will still have exclusive jurisdiction over these matters.
Possible Impacts
1. Individuals who are enrolled in a group health plan or individual or group health insurance coverage would now have the benefit of being able to choose their preferred doctor of optometry, doctor of dental surgery, or doctor of dental medicine without any restrictions or limitations set by the plan or coverage.
2. Doctors of optometry, dental surgery, and dental medicine who have an agreement to participate in a plan or coverage would have the opportunity to charge enrollees for items or services that are not covered by the plan or coverage, as long as the amount charged is equal to or less than the usual and customary amount they would charge individuals who are not enrolled in the plan or coverage.
3. A person who has been adversely affected by a violation of the legislation would have the right to bring action against the plan or coverage and could potentially receive monetary damages and attorney's fees. This gives individuals more power to hold their insurance providers accountable for any violations of the legislation.
[Congressional Bills 116th Congress]
[From the U.S. Government Publishing Office]
[S. 4894 Introduced in Senate (IS)]
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116th CONGRESS
2d Session
S. 4894
To amend title XXVII of the Public Health Service Act to improve health
care coverage under vision and dental plans, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
November 12, 2020
Mr. Manchin (for himself and Mr. Cramer) introduced the following bill;
which was read twice and referred to the Committee on Health,
Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act to improve health
care coverage under vision and dental plans, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Dental and Optometric Care Access
Act of 2019'' or the ``DOC Access Act of 2019''.
SEC. 2. IMPROVING HEALTH CARE COVERAGE UNDER VISION AND DENTAL PLANS.
(a) In General.--Title XXVII of the Public Health Service Act is
amended by inserting after section 2719A (42 U.S.C. 300gg-19a) the
following new section:
``SEC. 2719B. IMPROVING COVERAGE UNDER VISION AND DENTAL PLANS.
``(a) In General.--Under a group health plan or individual or group
health insurance coverage (including such a plan or coverage offering
limited scope dental or vision benefits), the following shall apply:
``(1) Payment amounts from covered persons.--
``(A) In general.--The plan or coverage shall
provide that, with respect to a doctor of optometry,
doctor of dental surgery, or doctor of dental medicine
that has an agreement to participate in the plan or
coverage and that provides items or services that are
not covered services under the plan or coverage to a
person enrolled under such plan or coverage, the doctor
may charge the enrollee for such items or services any
amount determined by the doctor that is equal to, or
less than, the usual and customary amount that the
doctor charges individuals who are not so enrolled for
such items or services.
``(B) Items or services considered covered by a
plan.--For purposes of subparagraph (A), an item or
service shall be considered, with respect to a plan or
coverage, to be covered services under the plan or
coverage only if the item or service is an item or
service with respect to which the plan or coverage is
obligated to pay an amount that is reasonable and is
not nominal or de minimis.
``(C) Exception for dental cleaning.--For purposes
of subparagraph (A), a doctor of dental surgery or
doctor of dental medicine that has an agreement to
participate in the plan or coverage may charge an
enrollee only the contracted network fee for any dental
cleaning, including any dental cleaning that exceeds
the annual maximum under the enrollee's plan or
coverage.
``(2) Duration of limited scope vision and dental plans.--
In the case of an agreement between such a doctor and such a
plan or coverage that offers limited scope dental or vision
benefits--
``(A) the agreement may be extended for a term
longer than 2 years only with the prior acceptance of
the doctor for each such term extension; and
``(B) the agreement may be extended for unlimited
terms, subject to subparagraph (A).
``(3) No restrictions on choice of laboratories.--The plan
or coverage may not, directly or indirectly, restrict or limit,
such a doctor's choice of laboratories or choice of source and
suppliers of services or materials provided by the doctor to an
individual who is enrolled under the plan or coverage.
``(b) Private Right of Action.--In addition to any other remedies
under State or Federal law, a person adversely affected by a violation
of this subsection may bring action for injunctive relief against a
plan described in subsection (a) and, upon prevailing, in addition to
such injunctive relief shall recover monetary damages of no more than
$1,000 for each day found to be in violation plus attorney's fees and
costs. The district courts of the United States shall have exclusive
jurisdiction of civil actions brought under this subsection.
``(c) Relationship to Exception for Limited, Excepted Benefits.--
Section 2722(c)(1) shall not apply with respect to the requirements of
this section.
``(d) Election To Be Excluded.--
``(1) In general.--If a doctor of optometry, doctor of
dental surgery, or doctor of dental medicine to which the
provisions of paragraphs (1) and (3) of subsection (a)
otherwise apply makes an election under this paragraph (in such
form and manner as the Secretary may by regulations prescribe),
the requirements of such paragraphs insofar as they apply
directly to the plan or coverage shall not apply to such plan
or coverage for such period, as described in paragraph (2).
``(2) Period of election.--An election under paragraph
(1)--
``(A) shall apply for a single specified plan year;
``(B) may be extended through subsequent elections
under this subsection; and
``(C) shall not be available with respect to the
requirements concerning the duration of limited scope
vision and dental plans under subsection (a)(2).
``(e) Definitions.--In this section:
``(1) The term `covered services' means dental care or
vision care services for which reimbursement is available under
a plan or coverage contract, or for which reimbursement would
be available but for the application of contractual
limitations, including deductibles, copayments, coinsurance,
waiting periods, lifetime maximum, frequency limitations, and
alternative benefit payments.
``(2) The terms `doctor of dental surgery' and `doctor of
dental medicine' mean a doctor of dental surgery or of dental
medicine, as applicable, who is legally authorized to practice
dentistry by the State in which the doctor performs such
function and who is acting within the scope of the license of
the doctor when performing such functions.
``(3) The term `doctor of optometry' means a doctor of
optometry who is legally authorized to practice optometry by
the State in which the doctor so practices.''.
(b) Conforming Amendment.--Section 2722(c)(1) of the Public Health
Service Act (42 U.S.C. 300gg-21(c)(1)) is amended by striking ``The
requirements'' and inserting ``Subject to section 2719B, the
requirements''.
(c) Exclusive Applicability of State Law.--Notwithstanding any
amendment made by this Act, State law that directly affects any
standard or requirement relating to health insurance issuers and dental
or vision benefit plans, shall have exclusive application and the
amendments made by this Act shall not apply to the extent that such
State law conflicts with such amendments. The State shall retain
exclusive jurisdiction over health insurance issuers and limited scope
dental or vision benefit plans that are directly governed by such
State.
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