Connecticut General Statutes 38a-472h – Fees charged by dentists, optometrists and ophthalmologists for noncovered benefits. Notice and posting required
(a) No insurer, health care center, fraternal benefit society, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing:
Terms Used In Connecticut General Statutes 38a-472h
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Insurance: means any agreement to pay a sum of money, provide services or any other thing of value on the happening of a particular event or contingency or to provide indemnity for loss in respect to a specified subject by specified perils in return for a consideration. See Connecticut General Statutes 38a-1
- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy. See Connecticut General Statutes 38a-1
- Policy: means any document, including attached endorsements and riders, purporting to be an enforceable contract, which memorializes in writing some or all of the terms of an insurance contract. See Connecticut General Statutes 38a-1
- State: means any state, district, or territory of the United States. See Connecticut General Statutes 38a-1
(1) An individual or a group dental plan in this state shall include in any contract with a dentist licensed pursuant to chapter 379 that is entered into, renewed or amended on or after January 1, 2012, any provision that requires such dentist to accept as payment an amount set by such insurer, center, society, corporation or entity for services or procedures provided to an insured or enrollee that are not covered benefits under such insured’s or enrollee’s plan; or
(2) An individual or a group vision plan in this state shall include in any contract with an optometrist licensed pursuant to chapter 380 or an ophthalmologist licensed pursuant to chapter 370 that is entered into, renewed or amended on or after January 1, 2020, any provision that requires such optometrist or ophthalmologist to accept as payment an amount set by such insurer, center, society, corporation or entity for services, procedures or products provided to an insured or enrollee that are not covered benefits under such insured’s or enrollee’s plan.
(b) No dentist shall charge more for services or procedures that are not covered benefits than such dentist’s usual and customary rate for such services or procedures, and no optometrist or ophthalmologist shall charge more for services, procedures or products that are not covered benefits than such optometrist’s or ophthalmologist’s usual and customary rate for such services, procedures or products.
(c) (1) Each evidence of coverage for an individual or a group dental plan shall include the following statement:
“IMPORTANT: If you opt to receive dental services or procedures that are not covered benefits under this plan, a participating dental provider may charge you his or her usual and customary rate for such services or procedures. Prior to providing you with dental services or procedures that are not covered benefits, the dental provider should provide you with a treatment plan that includes each anticipated service or procedure to be provided and the estimated cost of each such service or procedure. To fully understand your coverage, you may wish to review your evidence of coverage document.”
(2) Each evidence of coverage for an individual or a group vision plan shall include the following statement:
“IMPORTANT: If you opt to receive optometric or ophthalmologic services, procedures or products that are not covered benefits under this plan, a participating optometrist or ophthalmologist may charge you his or her usual and customary rate for such services, procedures or products. Prior to providing you with optometric or ophthalmologic services, procedures or products that are not covered benefits, the optometrist or ophthalmologist should provide you with a treatment plan that includes each anticipated service, procedure or product to be provided and the estimated cost of each such service, procedure or product. To fully understand your coverage, you may wish to review your evidence of coverage document.”
(d) Each dentist, optometrist and ophthalmologist shall post, in a conspicuous place, a notice stating that services, procedures or products, as applicable, that are not covered benefits under an insurance policy or plan might not be offered at a discounted rate.
(e) The provisions of this section shall not apply to:
(1) A self-insured plan that covers (A) dental services or procedures, or (B) optometric or ophthalmologic services, procedures or products;
(2) A contract that is incorporated in or derived from a collective bargaining agreement or in which some or all of the material terms are subject to a collective bargaining process;
(3) A contract that is derived from a multiemployer plan, as defined in Section 3 of the Employee Retirement Income Security Act of 1974, as amended from time to time; or
(4) A network of ophthalmologists or optometrists, or both, when servicing a plan or contract described in subdivision (1), (2) or (3) of this subsection.