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NCOIL Adopts Dental Fee Model

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Members of the National Conference of Insurance Legislators (NCOIL) have approved a model act that could limit dental plans’ ability to impose balance-billing restrictions.

State lawmakers adopted the Model Act Banning Fee Schedules for Uncovered Dental Services recently in Austin, Texas, at NCOIL’s annual meeting.

“Balance billing” occurs when a care provider receives reimbursement from a patient’s insurer, then bills the patient directly for the difference between the amount charged and the amount the insurer has paid.

A medical or dental insurer often will prohibit a provider in its network from balance billing in-network patients who receive covered services.

In the network contract, an insurer and provider may agree that the amount the insurer pays — together with any co-payments, coinsurance payments or deductibles required of the patient – will fulfill the patient’s obligations to the provider.

The NCOIL model act distinguishes between balance-billing provisions that cover the services that a dental plan covers in-network and the services the dental plan does not cover, whether or not the patient is seeing an in-network dentist.

The model would let dental plans continue to prohibit balance billing for in-network services, but it would ban balance-billing restrictions on uncovered services.

From the perspective of dentists, it seems as if plans are now setting rates for the services they don’t cover as well as the services they do cover, according to

Rhode Island state Rep. Brian Kennedy, D-Hopkinton, R.I.

“With almost no bargaining power, dentists are left with little to no choice,” Kennedy says in a statement about the model. “They must accept these fees in order to keep their patients, forcing them to shift costs to the uninsured, or stop participating in the insurer’s network and lose their client base.”

Another model provision will keep contractors and independent administrators from leasing dental provider networks to a plan that sets fees for any services except covered services.

States that already have laws in place that are similar to the new model include Alaska, Arizona, California, Idaho, Iowa, Kansas, Louisiana, Mississippi, Nebraska, North Carolina, Oklahoma, Oregon, Rhode Island, South Dakota, Virginia and Washington, according to officials at NCOIL, Troy, N.Y.


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