March 2019 Volume LIV Number 2

 
 
 
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Litch's Law Log: Iowa Supreme Court Affirms Non-Covered Services Law

March 2014 Volume L Number 2

BACKGROUND

The AAPD is supportive of state dental association efforts to obtain non-covered services legislation. For example, in November 2013 the AAPD sent letters to legislators in Florida and Ohio in support of pending non-covered services legislation. This legislation would prevent insurers from setting prices for services their plans do not even cover. The AAPD believes such insurance practices hurt access to care and interfere with the patient-doctor relationship. Fortunately, laws preventing such practices have already been approved in 33 states. The pending non-covered services bills are strongly supported by the Florida Dental Association and the Ohio Dental Association, as well as the respective pediatric dental associations in each state.1

 

IOWA LAW AND INTERPRETATION DISPUTE

The Iowa Dental Association worked to obtain passage of a noncovered services law in 20102 that prohibits dental plans from requiring a contracting dentist to provide services to covered individuals at a fee set by the dental plan unless such services are covered (meaning reimbursed) by the plan.

 

However, the story did not end there. Some insurers continued to place limits on services that were potentially "reimbursable" but not actually reimbursed because of a contractual plan limit, such as a patient being under a deductible amount or over an annual limit on coverage. Hence, the dental association raised the matter with the state insurance commissioner, who agreed with the insurers. Judicial review was then sought and a state district court also agreed with the insurers. However, at the next level the Iowa Supreme Court reached a difference conclusion. The Iowa Supreme Court held in a May 17, 2013, opinion that a service is "covered" only if it is actually reimbursed to some extent under the dental plan.3

 

IMPLEMENTING THE COURT DECISION

Subsequent to that court decision, the state's insurance division issued a notice to dental insurers on Oct. 15, 2013, indicating it would enforce complaints of any rate caps wrongfully imposed by insurers or for any misrepresentations of the decision by insurers. Iowa's largest dental insurer, Delta Dental of Iowa, notified its policyholders that on Nov. 1, 2013, it would begin adhering to the Iowa Supreme Court ruling. This means that once a patient has exhausted the maximum benefit for a particular dental service under his or her dental plan, the insurer cannot cap the fee the treating dentist may charge the specific patient for that dental service for the balance of the coverage period under the remaining terms and conditions of the patient's dental plan. As one example, if a dental plan pays in whole or in part for two teeth cleanings per year and the patient's family requests a third cleaning during the 12-month period, the patient is "off the plan" for the third cleaning and the insurer cannot dictate the fee charged by the treating dentist. See the state notice to Iowa Dental Insurers at http://www.iid. state.ia.us/node/6887896.

 

Delta Dental indicated it would reimburse policyholders for the difference between what dentists charged and the contracted or discounted fee it initially reimbursed, retroactively between the date of the Supreme Court ruling (May 17, 2013) through Nov. 1, 2013, with insurance holders having until April 30, 2014, to submit requests for reimbursement.

 

IMPORTANCE FOR DENTISTS

Larry Carl, executive director of the Iowa Dental Association (IDA) stated to local media that insurers were "overreaching in their contractual relationship with dentists." "The insurance industry viewed setting a maximum on some services as some sort of marketing advantage. It's like they were saying, 'We have such market control here in Iowa that we can dictate to dentists that we can charge to dentists what we don't even cover.'"

 

"This was a huge victory for dentists and for small businesses," said Dr. Mary Mariani, IDA president. "This is a victory for our autonomy. It's the patients and the dentists making the decisions rather than the insurance companies."

 

The lesson from this case is an important nuance to understand for those state advocates seeking non-covered services legislation in their state, as well as those monitoring implementation in the 33 states that have already passed such laws.

 

For further information contact Chief Operating Officer and General Counsel C. Scott Litch at (312) 337-2169, ext. 29, or slitch@ aapd.org.

See this link for more details: http://aapd-oldsite.ae-admin.com/aapd_supports_non-covered_services_legislation_in_florida_and_ohio/ H.F. 2229. Iowa Dental Association v. Iowa Insurance Division et al., 831 N.W.2d 138 (Iowa 2013).


 

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