Monique Limón

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act's requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law imposes specified coverage and disclosure requirements on health care service plans and health insurers, including specialized plans and insurers, that cover dental services.

This bill would require a health care service plan or health insurer that provides payment directly or through a contracted vendor to a dental provider to have a non-fee-based default method of payment, as specified. The bill would require a health care service plan, health insurer, or contracted vendor to obtain affirmative consent from a dental provider who opts in to a fee-based payment method before the plan or vendor provides a fee-based payment method to the provider. The bill would authorize a dental provider to opt out of a fee-based payment method at any time by providing affirmative consent to the health care service plan, health insurer, or contracted vendor. The bill would require a health care service plan, health insurer, or contracted vendor that obtains affirmative consent to opt in or opt out of fee-based payment to apply the decision to include both the dental provider's entire practice and all products or services covered pursuant to a contract with the dental provider, as specified. The bill would specify that its provisions do not apply if a health care service plan or health insurer has a direct contract with a provider that allows the provider to choose payment methods, including a non-fee-based payment method for services rendered. The bill would make its provisions operative on April 1, 2026, and apply to health care service plan contracts and health insurance policies issued, amended, or renewed on or after that date.

Because a violation of the bill's requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.