33-24-59.15. Definitions; dental insurance; prohibited activities.

As used in this Code section:#

1. (1)

   “Care management organization” shall have the same meaning as set forth in Code Section 33-21A-2.#

2. (2)

   “Covered dental services” means dental care services for which a reimbursement is available under a covered person’s dental benefit plan, 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 limitation.#

3. (3)

   “Covered person” means any subscriber, enrollee, member, beneficiary, or participant, or his or her dependent, for whom benefits are payable when that covered person receives dental care services rendered or authorized by a dentist licensed under Chapter 11 of Title 43.#

4. (4)

   “Dental benefit plan” means any individual or group plan, policy, contract, or subscription agreement which includes or is for dental care services that is issued, delivered, issued for delivery, or renewed in this state whether by a healthcare insurer, health maintenance organization, preferred provider organization, accident and sickness insurer, fraternal benefit society, healthcare plan, or any other person, firm, corporation, joint venture, or other similar business entity that pays for, purchases, or furnishes dental care services to patients, insureds, beneficiaries, or covered dependents in this state.#

5. (5)

   “Dental insurer” means any person, firm, corporation, joint venture, or other similar business entity that offers dental benefit plans in consideration of periodic payments.#

No contract between a dental insurer and a dentist shall require a dentist to accept an amount set by the dental insurer as payment for dental care services that are not covered dental services under the covered person’s dental benefit plan.#

A dental insurer or other person or entity providing third-party administrator services shall not make available any providers in its dentist network to a plan that sets dental fees for any services except covered services.#

A dental insurer shall not draft, publish, disseminate, or circulate explanation of benefit forms that include language which directly or indirectly implies that a dentist may or should extend discounts to patients for noncovered dental services. Statements by a dental insurer which are prohibited by this Code section include but are not limited to, Our members value the services you provide and we encourage you to continue extending the discount on noncovered services.#

Any dental benefit plan issued, amended, or renewed on or after January 1, 2026, between a dental insurer, contracted vendor thereof, or a care management organization and a healthcare provider for the provision of healthcare services to a plan enrollee may provide coverage for the cost of dental care provided through teledentistry as directed through regulations promulgated by the Commissioner.#

A dental insurer, contracted vendor thereof, or care management organization shall not:#

1. (1)

   Exclude a service appropriately provided through teledentistry from coverage solely because the service is provided through teledentistry and is not provided through in-person consultation or contact between an authorizing dentist and a patient; or#

2. (2)

   Require its insureds to receive dental care through teledentistry in lieu of an in-person, clinical examination.#

As used in this Code section:#

1. (1)

   “Covered dental services” means dental care services for which a reimbursement is available under a covered person’s dental benefit plan, 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 limitation.#

2. (2)

   “Covered person” means any subscriber, enrollee, member, beneficiary, or participant, or his or her dependent, for whom benefits are payable when that covered person receives dental care services rendered or authorized by a dentist licensed under Chapter 11 of Title 43.#

3. (3)

   “Dental benefit plan” means any individual or group plan, policy, contract, or subscription agreement which includes or is for dental care services that is issued, delivered, issued for delivery, or renewed in this state whether by a health care insurer, health maintenance organization, preferred provider organization, accident and sickness insurer, fraternal benefit society, health care plan, or any other person, firm, corporation, joint venture, or other similar business entity that pays for, purchases, or furnishes dental care services to patients, insureds, beneficiaries, or covered dependents in this state.#

4. (4)

   “Dental insurer” means any person, firm, corporation, joint venture, or other similar business entity that offers dental benefit plans in consideration of periodic payments.#

No contract between a dental insurer and a dentist shall require a dentist to accept an amount set by the dental insurer as payment for dental care services that are not covered dental services under the covered person’s dental benefit plan.#

A dental insurer or other person or entity providing third-party administrator services shall not make available any providers in its dentist network to a plan that sets dental fees for any services except covered services.#

A dental insurer shall not draft, publish, disseminate, or circulate explanation of benefit forms that include language which directly or indirectly implies that a dentist may or should extend discounts to patients for noncovered dental services. Statements by a dental insurer which are prohibited by this Code section include but are not limited to, “Our members value the services you provide and we encourage you to continue extending the discount on noncovered services.”#