The Impact of SB 1144
The Pennsylvania Dental Association, working in conjunction with the dental insurance carriers, supported SB 1144, which was signed into law Oct. 25, 2012 and took effect Dec. 25, 2012. The Act applies to all dental insurance contracts written in Pennsylvania after that date.
PDA supported SB 1144 because some insurance carriers wanted to limit dentists from billing their full amount for services that are not covered under the terms of the patient’s contract. In order to obtain some protection from the insurance carriers’ intentions, PDA and the insurance carriers agreed to a compromise that stipulates a dentist can be held to the insurance carriers’ allowances only under specific circumstances.
According to the Act, if a dentist signed an agreement with an insurance carrier, the dentist is obligated to accept the insurance carrier’s allowance – even if the insurance carrier does not make payment – if the reason for nonpayment is based on one of the following scenarios:
- Deductible has not been satisfied
- Co-insurance is applicable
- Patient reached a lifetime or annual maximum
- Service is limited by frequency
- Payment was made for an alternate form of treatment
However, even if a dentist signs an agreement with an insurance carrier, the dentist can bill up to his/her charge for services that are not covered under the terms of that particular patient’s contract.
- If a patient has coverage for basic, diagnostic and preventive services, but does not have coverage for prosthetics, the dentist can bill his/her own fee for crowns and other prosthetic services.
- On the other hand, if the same patient’s coverage provides for only one prophylaxis a year and the patient has two, even though the carrier will not pay for the second, the dentist is limited to collecting from the patient the amount of the carrier’s allowance.
- And, if the dentist places a composite restoration and patient has coverage for both amalgam and composite restorations, the insurance carrier may make an allowance for an amalgam under the alternate treatment provision and the dentist may bill up to the carrier’s allowance for a composite.
Further, the Act stipulates that insurance companies may not require
a participating dentist to limit their charge to patients for non-covered services. Rather, the dentists are to be given the option to do so.
Dentists who participate with insurance companies are being asked to sign
contracts that will prohibit them from charging patients their usual and
customary fees for non-covered dental services. The impact of this contractual
change for dental practices could be significant if the reimbursement for
non-covered services is too low for dentists to cover their overhead expenses,
pay their employees, etc. Dentists may have to choose between economic hardship
and disrupting relationships with patients if they are forced to drop out of
network. Ultimately, it is unfair for insurers to dictate fees on services they
arbitrarily decide not to cover. Once the terms of the contact between the
insurer and patient are met, treatment and payment options should be arranged
between the provider and patient only.
PDA made passage of this legislation its priority for the 2011-2012
legislative session. Understanding the financial impact this policy has on those
members participating with insurance companies, PDA’s lobbyists, staff and
volunteer members met continuously with senators and representatives to discuss
the need to pass SB 1144. These collective efforts paid off - the Senate passed
SB 1144 in June and the House of Representatives passed it in October. SB 1144
moved to Gov. Corbett for his signature on October 25. The bill takes effect 60
days after his signature. SB 1144 will prohibit insurers from
limiting the amount a dentist can charge for non-covered services. The bill will
apply to new and renewed employer contracts.
PDA thanks all of you who helped achieve PDA's advocacy goal by requesting
support for this issue from your legislators. Your participation in these
grassroots efforts was essential to gaining the clout needed to silence the
insurance lobby's opposition and garner enough votes to pass SB 1144 through the