AB251: Bill Text

LRB-1603/2

PJK:jld:rs

2011 - 2012 LEGISLATURE

2011 Assembly BILL 251

September 15, 2011 - Introduced by Representatives Wynn, Danou, Endsley, Bernier, Spanbauer, Thiesfeldt, Nass, A. Ott, Petrowski, Young, Nerison, Kaufert, Pridemore, Doyle, Knilans, Krug, Petryk, Mason, Kuglitsch, Strachota, Loudenbeck, Ballweg, Ripp, Stone, Bernard Schaber, Tranel, Williams and Vos, cosponsored by Senators Wanggaard, Holperin, Galloway, Lasee, Vinehout, Moulton, Lazich, Hansen and Schultz. Referred to Committee on Insurance.

AB251,1,1 An Act to create 632.873 of the statutes; relating to: fees for dental services.

Analysis by the Legislative Reference Bureau

Under this bill: 1) an insurer that offers a policy or plan that provides coverage for dental and related services may not require a dentist who provides services under the policy or plan to provide a service to an enrollee of the plan at a fee set by the insurer if the service is not covered under the policy or plan (noncovered service); 2) an administrator providing third-party administration services or a provider network for a plan that provides coverage for dental and related services may not require any dentist in the administrator's provider network to charge set fees for noncovered services provided to enrollees of the plan; and 3) a dentist who provides services to enrollees of a policy or plan that provides coverage for dental and related services may not charge an enrollee more than the dentist's usual nondiscounted fee for a noncovered service.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

AB251, s. 1 Section 1. 632.873 of the statutes is created to read:

AB251,2,2 632.873 Restrictions relating to fees for dental services. (1) Definition. In this section, "covered service" means, with respect to dental or related services specified in a policy or plan that provides coverage for those services, a service provided by a dentist to an enrollee of the policy or plan to which all of the following apply:

AB251,2,4 (a) The policy or plan makes a payment for the service, administered consistently with policies traditionally governing covered services.

AB251,2,6 (b) The policy's or plan's allowed amount for the service on behalf of the enrollee is more than 50 percent of the dentist's usual nondiscounted fee for the service.

AB251,2,11 (2) Prohibitions on setting fees. (a) A contract between an insurer offering a policy or plan that provides coverage for dental and related services and a dentist for the provision of dental and related services to enrollees of the policy or plan may not require the dentist to provide a service to an enrollee of the policy or plan at a fee set by the insurer unless the service is a covered service under the policy or plan.

AB251,2,16 (b) An administrator providing 3rd-party administration services or a provider network for a plan that provides coverage for dental and related services may not require any dentist in the administrator's provider network that is eligible to provide services under the plan to charge set fees for dental or related services provided to enrollees of the plan that are not covered services under the plan.

AB251,2,21 (3) Prohibition on charges. A dentist who, under a contract with an insurer or other person offering a policy or plan that provides coverage for dental and related services, provides dental or related services to an enrollee of the policy or plan may not charge the enrollee more than the dentist's usual nondiscounted fee for a dental or related service that is not a covered service under the policy or plan.

AB251, s. 2 Section 2. Initial applicability.

AB251,3,2 (1) If a contract that is in effect on the effective date of this subsection contains a provision that is inconsistent with the treatment of section 632.873 (2) (a) or (b) or (3) of the statutes, the treatment of section 632.873 (2) (a) or (b) or (3) of the statutes first applies to that contract on the date on which it is modified or renewed.

AB251,3,3 (End)