Prohibited contract provisions in contracts between carriers and providers for dental services - definition
(1) A contract between a carrier and a dentist licensed to practice under article 220 of title 12 must not require, directly or indirectly, that a dentist who is a participating provider provide services to a covered person at a fee set by, or subject to the approval of, the carrier unless:
(a)The services are covered services under the person's…#
(a) The services are covered services under the person's policy; and
(b)The carrier provides payment for the services under the…#
(b) The carrier provides payment for the services under the person's policy in an amount that is reasonable and not nominal or de minimis.
(2) The dentist may charge the covered person for noncovered items or services in any amount determined by the dentist and agreed to by the patient that is equal to, or less than, the usual and customary amount that the dentist charges individuals who do not have coverage for such items and services.
(3) If the commissioner determines that a carrier has not complied with this section, the commissioner shall institute a corrective action plan that the carrier shall follow or may use any of the commissioner's enforcement powers to obtain the carrier's compliance with this section.
(4) For purposes of this section, covered services means dental care services for which reimbursement is available under a covered person's plan contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other contractual limitations.