§1156.  Dental reimbursement or payments

A.  Every company that issues, delivers, amends, or renews a policy of dental insurance in this state providing coverage for dental health care treatment which provides that the payment of benefits under the policy shall be based upon the usual and customary fee charged by licensed dentists shall contain all of the following disclosure requirements:

(1)  The frequency of the determination of the usual and customary fee.

(2)  A specific and detailed description of the methodology used to determine the usual and customary fee.

(3)  The percentile that determines the maximum benefit that the company will pay for each dental procedure, if the usual and customary fee is determined by taking a sample of fees submitted on actual claims from licensed dentists and then determining the benefit by selecting a percentile of those fees.

B.  Each insurer providing dental health coverage shall, upon request, provide a complete copy of the dental health coverage provisions, including the information enumerated in Subsection A of this Section, to each insured.  Every employee benefit explanation or description and any proposal for dental insurance coverage shall also contain such information regarding the determination of the usual and customary fee.

C.  As used in this Section, the following definitions shall apply:

(1)  "Usual fee" is the fee which an individual dentist most frequently charges for a specific dental procedure.

(2)  "Customary fee" is the fee level determined by the administrator of the dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for that specific procedure.

D.  The disclosure must be provided upon request to all group and individual policyholders and group certificate holders.  All proposals for dental insurance must notify the prospective policyholder that information regarding usual and customary fee determinations are available from the insurer.  The employee benefit descriptions or supplemental documents must notify the employee that information regarding dental reimbursements rates are available from the employer.

Acts 1992, No. 329, §1; Redesignated from R.S. 22:213.5 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.