Virginia Code 38.2-6105: Required dental benefit contract provisions
A. Each dental benefit contract shall contain the following provisions:
Terms Used In Virginia Code 38.2-6105
- Contract: A legal written agreement that becomes binding when signed.
- Copayment: means the amount payable for a particular service by an enrollee in accordance with the patient charge schedule or for which the enrollee is responsible as a condition for receiving benefits under a dental benefit contract. See Virginia Code 38.2-6101
- Dental benefit contract: means a contract that provides benefits for dental services entered into between the dental plan organization and a contract holder. See Virginia Code 38.2-6101
- Dental plan: means a contractual arrangement for dental services provided or arranged for, that pays benefits or is administered on an individual or group basis. See Virginia Code 38.2-6101
- Dental plan organization: means a company that provides directly or arranges for a dental plan. See Virginia Code 38.2-6101
- Enrollee: means an individual or a dependent of an individual who is enrolled in a dental plan. See Virginia Code 38.2-6101
- Fixed indemnity benefits: means the payment amount or amounts stated in the reimbursement schedule of a dental plan organization that will be paid to a subscriber, or to the subscriber's dentist, for dental services. See Virginia Code 38.2-6101
- Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. Source: Federal Reserve
- Plan dentist: means any dentist, licensed by the Virginia Board of Dentistry, who has contracted with the dental plan organization or with an entity acting on behalf of the dental plan organization to provide dental services to the enrollees. See Virginia Code 38.2-6101
1. An effective date of the contract;
2. A provision describing the payment of required subscription fees or premiums;
3. A grace period provision that complies with § 38.2-6107;
4. For group dental benefit contracts, the eligibility requirements and effective date of coverage for subscribers of the group and their dependents;
5. A provision describing the benefits available under the dental benefit contract;
6. A provision describing the copayments and deductibles for which the enrollee is responsible or the fixed indemnity benefits, if any;
7. A provision describing the service area, if applicable;
8. If a dental plan organization provides benefits only within a stated service area, a provision providing for emergency dental services outside the service area, with the term “emergency” including care to alleviate acute pain;
9. A provision indicating that if a plan dentist refers the enrollee to a specialist who is not a plan dentist for dental services that are covered under the dental benefit contract, the dental plan organization shall be responsible for payment of the specialist’s charges to the extent the charges exceed the copayment specified in the dental benefit contract;
10. A provision that reads substantially as follows, if the contract requires use of a plan dentist:
“If during the term of this contract none of the plan dentists can render necessary care and treatment to the enrollee due to circumstances not reasonably within the control of the dental plan organization, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, or the disability of a significant number of the plan dentists, then the enrollee may seek treatment from an independent licensed dentist of his own choosing. The dental plan organization will pay the enrollee for the expenses incurred for the dental services with the following limitations: The dental plan organization will pay the enrollee for services that are listed in the patient charge schedule as “No Charge,” to the extent that such fees are reasonable and customary for dentists in the same geographic area; the dental plan organization will also pay the enrollee for those services listed in the contract for which there is a copayment, to the extent that the reasonable and customary fees for such services exceed the copayment for such services as set forth in the contract. The enrollee may be required to give written proof of loss.”;
11. A provision setting out the terms under which coverage will terminate; and
12. A provision setting out a grievance procedure that specifies the time period in which the dental plan organization shall initially respond to an enrollee’s grievance, with the time period not exceeding 20 days from the date the grievance is filed with the dental plan organization.
B. Each dental benefit contract shall also have provisions related to extension of benefits that specify:
1. If an enrollee’s coverage terminates, an extension of benefits shall be provided for any treatment in progress at the time of termination, provided the treatment requires two or more visits to the dentist’s office on separate days as certified by the treating dentist.
2. The extension of benefits shall be, at a minimum, for all types of dental care other than orthodontics, until the completion of the procedure.
3. For orthodontics, the extension of benefits will be at least 60 days if the orthodontist has agreed to or is receiving monthly payments when coverage terminates, or if the orthodontist has agreed to accept or is receiving payments on a quarterly basis, to the end of the quarter in progress or 60 days, whichever is longer.
4. An extension of benefits is not required if termination is due solely to the failure of the enrollee to pay the subscription fee or premium when the enrollee is otherwise eligible to continue coverage under the dental benefit contract.
2004, c. 668.