Utah Code 31A-22-646.1. Leasing requirements for dental plans
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(1) As used in this section:
Terms Used In Utah Code 31A-22-646.1
- Administrator: means the same as that term is defined in Subsection (187). See Utah Code 31A-1-301
- Affiliate: means a person who controls, is controlled by, or is under common control with, another person. See Utah Code 31A-1-301
- 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.
- Corporation: means an insurance corporation, except when referring to:(34)(a)(i) a corporation doing business:(34)(a)(i)(A) as:(34)(a)(i)(A)(I) an insurance producer;(34)(a)(i)(A)(II) a surplus lines producer;(34)(a)(i)(A)(III) a limited line producer;(34)(a)(i)(A)(IV) a consultant;(34)(a)(i)(A)(V) a managing general agent;(34)(a)(i)(A)(VI) a reinsurance intermediary;(34)(a)(i)(A)(VII) a third party administrator; or(34)(a)(i)(A)(VIII) an adjuster; and(34)(a)(i)(B) under:(34)(a)(i)(B)(I) Chapter 23a, Insurance Marketing - Licensing Producers, Consultants, and Reinsurance Intermediaries;(34)(a)(i)(B)(II) Chapter 25, Third Party Administrators; or(34)(a)(i)(B)(III) Chapter 26, Insurance Adjusters; or(34)(a)(ii) a noninsurer that is part of a holding company system under Chapter 16, Insurance Holding Companies. See Utah Code 31A-1-301
- Enrollee: includes an insured. See Utah Code 31A-1-301
- Form: means one of the following prepared for general use:
(74)(a)(i) a policy;(74)(a)(ii) a certificate;(74)(a)(iii) an application;(74)(a)(iv) an outline of coverage; or(74)(a)(v) an endorsement. See Utah Code 31A-1-301- Health benefit plan: means a policy, contract, certificate, or agreement offered or issued by an insurer to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care, including major medical expense coverage. See Utah Code 31A-1-301
- health insurance: means insurance providing:
(84)(a)(i) a health care benefit; or(84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301- Individual: means a natural person. See Utah Code 31A-1-301
- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- insurance company: means a person doing an insurance business as a principal including:
(104)(a)(i) a fraternal benefit society;(104)(a)(ii) an issuer of a gift annuity other than an annuity specified in Subsections31A-22-1305 (2) and (3);(104)(a)(iii) a motor club;(104)(a)(iv) an employee welfare plan;(104)(a)(v) a person purporting or intending to do an insurance business as a principal on that person's own account; and(104)(a)(vi) a health maintenance organization. See Utah Code 31A-1-301- Lease: A contract transferring the use of property or occupancy of land, space, structures, or equipment in consideration of a payment (e.g., rent). Source: OCC
- Network provider: means a health care provider who has an agreement with a managed care organization to provide health care services to an enrollee with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the managed care organization. See Utah Code 31A-1-301
- Participating: means a plan of insurance under which the insured is entitled to receive a dividend representing a share of the surplus of the insurer. See Utah Code 31A-1-301
- Person: includes :
(146)(a) an individual;(146)(b) a partnership;(146)(c) a corporation;(146)(d) an incorporated or unincorporated association;(146)(e) a joint stock company;(146)(f) a trust;(146)(g) a limited liability company;(146)(h) a reciprocal;(146)(i) a syndicate; or(146)(j) another similar entity or combination of entities acting in concert. See Utah Code 31A-1-301- Rate: means :
(163)(a)(i) the cost of a given unit of insurance; or(163)(a)(ii) for property or casualty insurance, that cost of insurance per exposure unit either expressed as:(163)(a)(ii)(A) a single number; or(163)(a)(ii)(B) a pure premium rate, adjusted before the application of individual risk variations based on loss or expense considerations to account for the treatment of:(163)(a)(ii)(B)(I) expenses;(163)(a)(ii)(B)(II) profit; and(163)(a)(ii)(B)(III) individual insurer variation in loss experience. See Utah Code 31A-1-301- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
- Writing: includes :
(48)(a) printing;(48)(b) handwriting; and(48)(c) information stored in an electronic or other medium if the information is retrievable in a perceivable format. See Utah Code 68-3-12.5(1)(a) “Contracting entity” means a person that enters into a direct contract with a provider for the delivery of dental services in the ordinary course of business, including a third party administrator or a dental carrier.(1)(b) “Dental carrier” means a dental insurance company, dental service corporation, or dental plan organization authorized to provide a dental plan.(1)(c) “Dental plan” means the same as that term is defined in Section 31A-22-646.(1)(d)(1)(d)(i) “Dental services” means services for the diagnosis, prevention, treatment, or cure of a dental condition, illness, injury, or disease.(1)(d)(ii) “Dental services” does not include services that a provider delivers and bills as medical expenses under a health benefit plan.(1)(e)(1)(e)(i) “Dental service contractor” means an individual who:(1)(e)(i)(A) accepts prepayment for dental services; or(1)(e)(i)(B) for the benefit of another individual, accepts payment for providing to the individual the opportunity to receive dental services in the future.(1)(e)(ii) “Dental service contractor” does not include a provider or professional dental corporation that accepts prepayment on a fee-for-service basis for providing specific dental services to individual patients for whom the services have been pre-diagnosed.(1)(f)(1)(f)(i) “Provider” means a person who, acting within the scope of licensure or certification, provides dental services or supplies defined by the dental plan.(1)(f)(ii) “Provider” does not include a physician organization or physician hospital organization that leases or rents the physician organization’s or physician hospital organization’s network to a third party.(1)(g) “Provider network contract” means a contract between a contracting entity and a provider that:(1)(g)(i) specifies the rights and responsibilities of the contracting entity; and(1)(g)(ii) provides for the delivery and payment of dental services to an enrollee.(1)(h)(1)(h)(i) “Third party” means a person that enters into a contract with a contracting entity or with another third party to gain access to the dental services or contractual discounts of a provider network contract.(1)(h)(ii) “Third party” does not include an employer or other group for whom the dental carrier or contracting entity provides administrative services.(2) A contracting entity may grant a third party access to a provider network contract regarding dental services, including a provider’s dental services, or a contractual discount provided under a provider network contract for dental services if:(2)(a) if the contracting entity is an insurer, the insurer complies with Subsection (3);(2)(b) the contract between the contracting entity and a person subject to the third-party access complies with Subsection (4); and(2)(c) the contracting entity complies with Subsection (5).(3) An insurer shall:(3)(a) at the time a contract is entered into or renewed, or when there is a material modification to a contract that is relevant to third-party access to a provider network contract, allow a provider which is part of the insurer’s provider network to:(3)(a)(i) choose to not participate in third-party access; or(3)(a)(ii) enter into a contract directly with the third party that acquired the provider network;(3)(b) allow a provider to opt out of lease arrangements without canceling or ending a contractual relationship with the insurer; and(3)(c) when initially contracting with a provider, accept a qualified provider even if a provider rejects a network lease provision.(4) A contracting entity described in Subsection (2) shall ensure that the contract described in Subsection (2)(b) includes the following:(4)(a) a provision indicating the contracting entity may enter into an agreement with a third party to allow the third party to obtain the contracting entity’s rights and responsibilities as if the third party were the contracting entity;(4)(b) if the contracting entity is a dental carrier, a provision indicating that the provider chose to participate in third-party access at the time the provider network contract was entered into or renewed; and(4)(c) if the contracting entity is an insurer, a provision indicating:(4)(c)(i) that the contract grants a third party access to the provider network; and(4)(c)(ii) for a contract with a dental carrier, the dentist has the right to choose not to participate in third-party access.(5) A contracting entity shall:(5)(a) provide a provider, in writing or electronic form, each third party in existence as of the date the contract is entered into;(5)(b) maintain a list of each third party in existence on the contracting entity’s website that is updated at least once every 90 days;(5)(c) require a third party to identify the source of the discount on all remittance advices or explanations of payment under which a discount is taken unless the transaction is an electronic transaction mandated by the Health Insurance Portability and Accountability Act;(5)(d) notify a third party of the termination of a provider network contract no later than 30 days after the day on which the contract terminates with the contracting entity;(5)(e) at least 30 days before the day on which a third party begins leasing a network provider, notify each network provider subject to the lease;(5)(f) make available to a participating provider, within 30 days after the day on which the provider makes a request, a copy of the provider network contract at issue in the adjudication of a claim; and(5)(g) maintain a list of the contracting entity’s affiliates on the contracting entity’s website.(6) A third party that gains access to a contract under this section:(6)(a) shall comply with each term of the contract to which the third party gains access; and(6)(b) loses all rights to a provider’s discounted rate as of the termination date of the provider network contract.(7) A contracting entity or third party may not require a provider to perform services under a provider network contract if a third party gains access to a contract in violation of this section.(8) This section does not apply to:(8)(a) a contracting entity granting access to a provider network contract to:(8)(a)(i) an entity that operates in accordance with the brand licensee program of the contracting entity; or(8)(a)(ii) an entity that is an affiliate of the contracting entity; and(8)(b) a provider network contract for dental services provided to beneficiaries of a state sponsored health program, including Medicaid and the Children’s Health Insurance Program.(9) A contract executed or renewed on or after January 1, 2022:(9)(a) may not waive the provisions of this section; and(9)(b) is null and void if the contract contains provisions that conflict with the provisions of this section or that purports to waive a requirement of this section.