The California Dental Association (CDA) played a role in sponsoring recent legislation that was signed into law and will be effective from January 1, 2025. The CDA-sponsored bill, now a law, aims to enhance dental plan disclosures for both dentists and patients. This statute is designed to help dental healthcare providers and patients have a clearer understanding of the type of insurance plan before the billing process begins. The mandated disclosure will require insurance plans to openly specify whether their coverage is regulated by federal or state authorities. This transparency will enable both doctors and patients to easily identify the relevant regulatory agency to contact in case of any grievances.
California Bill, AB 952 was authored by Assembly member Jim Wood (D-Healdsburg) and signed into law by Governor Gavin Newsome on July 27, 2023.
Legislation was specifically targeted toward a lack of open disclosures with dental insurance.
Confusion often arises due to the distinction between insurance coverage referred to as “fully insured,” which is regulated at the state level, and “self-insured” plans that operate under the federal Employee Retirement Income Security Act of 1974 (ERISA) statutes. ERISA plans are exempt from compliance with California (and most state) laws, and they frequently lead to frustrations for both patients and dental providers.
Specifically, AB 952 requires that dental benefit plans at the time of determining patient coverage:
- Disclose through their online patient portal whether the patient’s plan is state regulated.
- Disclose upon the dental office’s request whether the patient’s plan is state regulated. This requirement is especially relevant for plans that do not have a patient portal.
- Include the phrase “state regulated” on the patient’s electronic or physical insurance identification card—or both if they exist.
Wood stated, “It is vital for patients and providers to be aware of which laws apply to a patient’s dental plan. What we have now instead is a profound lack of clarity about the standards the plans must meet and where patients and dentists can go to resolve a conflict with a plan. The ERISA notification will provide that clarity for the millions of Californians enrolled in these plans and will help alleviate confounding billing processes for dental offices too.”
In a statement provided to Dentistry Today, CDA president, Dr. John Blake offered, “With over 40% of Californians enrolled in dental plans that are regulated under federal ERISA law rather than state law, the resulting confusion can be all too common for patients and dental offices. AB 952 is a good step toward addressing that through improved transparency.”
Additional importance of such legislation was addressed by author of 2022 Massachusetts Question 2 on dental insurance medical loss ratios, Mouhab Z. Rizkallah, DDS.
“I think there is real value in this new California Law.” Rizkallah added, “I actually love this law—it is an easy way to strengthen sloppy ERISA management (though most of them are already quite good).”
Rizkallah delivered the following overview:
What are these plans?
ERISA plans (which are a type of self-funded plan that has FEDERAL control and no STATE control) are a fiduciary plan that is frequently used by unions, etc. (generally great coverage—if managed properly).
Most plans are not federal ERISA plans—they are just commercial plans licensed by the state (and under state control).
The failures of the plans are different in nature.
ERISA plans (federally regulated) are sometimes bad when they are “poorly managed” by their fiduciaries.
Commercial plans (state regulated) are usually bad when “insurers intentionally cheat” to make more money.
Taken together:
If you want to regulate a “poorly managed” ERISA plan—you threaten them with civil and/or criminal court (they are fiduciaries).
If you want to regulate an “intentionally unfair” standard commercial plan—you threaten them with a complaint to the state division (department) of insurance.
In Summary:
By knowing exactly which category the insurance plan is in, patients and dentists are empowered to hit them in the right place (rather than feel hopeless because they don’t even know where to begin).
This law (by its mere existence) puts sloppy ERISA managers on notice—they will be held to their fiduciary responsibilities.
ABOUT THE AUTHOR
Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation.
Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee.
He can be reached at MWDavisDDS@Comcast.net.
FEATURED IMAGE CREDIT: Phloxii/Shutterstock.com.
