2013 - 2014 LEGISLATURE
March 29, 2013 - Introduced by Representatives Ballweg, Petersen, Nygren,
Barca, Berceau, Bernard Schaber, Bernier, Bewley, Bies, Billings, Brooks,
Clark, Danou, Doyle, Endsley, Genrich, Goyke, Hesselbein, Honadel,
Jacque, Jagler, Jorgensen, Kahl, Kaufert, Kerkman, Kestell, Klenke,
Kolste, Krug, Kuglitsch, LeMahieu, Loudenbeck, Marklein, Mason,
Murphy, Nass, Nerison, Ohnstad, A. Ott, Pasch, Petryk, Richards, Riemer,
Ringhand, Sargent, Schraa, Spiros, Stone, Strachota, Tauchen, Thiesfeldt,
Tittl, Tranel, Vruwink, Weatherston, Williams, Wright, Young and
Zamarripa, cosponsored by Senators Petrowski, Lasee, Cowles, Ellis,
Erpenbach, Gudex, Hansen, Harris, Harsdorf, Jauch, Lazich, Lehman,
Miller, Moulton, Olsen, Schultz, Shilling, L. Taylor, Vinehout and Wirch.
Referred to Committee on Insurance.
AB109,1,1 1An 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 limited-scope policy that provides
coverage for dental and related services may not require a dentist who provides
services under the policy to provide a service to an insured under the policy at a fee
set by the insurer if the service is not covered under the policy (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 an insured under a limited-scope policy that provides coverage for dental
and related services may not charge the insured more than the dentist's usual
nondiscounted fee for a noncovered service. The bill prohibits a limited-scope policy
that provides coverage for dental and related services from providing nominal or de
minimis coverage for a dental or related service, making the service a covered
service, for the sole purpose of avoiding the requirement under the bill that prohibits
setting fees for noncovered services.
The people of the state of Wisconsin, represented in senate and assembly, do
enact as follows:
AB109,1 2Section 1. 632.873 of the statutes is created to read:
AB109,2,2
1632.873 Restrictions relating to fees for dental services. (1) Definitions.
2In this section, unless the context requires otherwise:
AB109,2,113 (a) "Covered service" means, with respect to dental or related services specified
4in a policy or plan that provides coverage for those services, a service provided by a
5dentist or at the direction of a dentist to an insured under the policy or an enrollee
6of the plan for which the policy or plan makes payment, administered consistently
7with policies traditionally governing covered services, or for which the policy or plan
8would make payment but for the application of contractual limitations of
9deductibles, copayments, coinsurance, waiting periods, annual maximums, lifetime
10maximums applicable to the same course of treatment, frequency limitations, or
11alternative benefit payments.
AB109,2,1312 (b) "Policy" means a policy, certificate, or contract of insurance that provides
13only limited-scope dental benefits.
AB109,2,1514 (c) "Related service" means a service that is commonly provided, by a dentist
15or at the direction of a dentist, in conjunction with a dental service.
AB109,2,20 16(2) Prohibitions on setting fees. (a) 1. A contract between an insurer offering
17a policy that provides coverage for dental and related services and a dentist for the
18provision of dental and related services to an insured under the policy may not
19require the dentist to provide a service to an insured under the policy at a fee set by
20the insurer unless the service is a covered service under the policy.
AB109,2,2321 2. A policy that provides coverage for dental and related services may not
22provide nominal or de minimis coverage for a dental or related service for the sole
23purpose of avoiding the requirements under subd. 1.
AB109,3,324 (b) An administrator providing 3rd-party administration services or a provider
25network for a plan that provides coverage for dental and related services may not

1require any dentist in the administrator's provider network that is eligible to provide
2services under the plan to charge set fees for dental or related services provided to
3enrollees of the plan that are not covered services under the plan.
AB109,3,8 4(3) Prohibition on charges. A dentist who, under a contract with an insurer
5offering a policy that provides coverage for dental and related services, provides
6dental or related services to an insured under the policy may not charge the insured
7more than the dentist's usual nondiscounted fee for a dental or related service that
8is not a covered service under the policy.
AB109,2 9Section 2. Initial applicability.
AB109,3,1210 (1) The treatment of section 632.873 (2) (a) 1. and (3) of the statutes first applies
11to a contract between an insurer offering a limited-scope dental policy and a dentist
12that is entered into, modified, or renewed on the effective date of this subsection.
AB109,3,1613 (2) The treatment of section 632.873 (2) (b) of the statutes first applies to a
14contract between an administrator providing 3rd-party administration services or
15a provider network for a plan and a dentist that is entered into, modified, or renewed
16on the effective date of this subsection.
AB109,3,1917 (3) The treatment of section 632.873 (2) (a) 2. of the statutes first applies to a
18limited-scope dental policy that is newly issued or renewed on the effective date of
19this subsection.
AB109,3 20Section 3. Effective date.
AB109,3,2121 (1) This act takes effect on January 1, 2014.
AB109,3,2222 (End)
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