DOC Access Act of 2021

II 117TH CONGRESS 1ST SESSION S. 1793 To amend title XXVII of the Public Health Service Act to improve health care coverage under vision and dental plans, and for other purposes. IN THE SENATE OF THE UNITED STATES MAY 24, 2021 Mr. MANCHIN (for himself and Mr. CRAMER) introduced the following bill; which was read twice and referred to the Committee on Health, Edu- cation, Labor, and Pensions A BILL To amend title XXVII of the Public Health Service Act to improve health care coverage under vision and dental plans, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as the ‘‘Dental and Optometric 4 Care Access Act of 2021’’ or the ‘‘DOC Access Act of 5 2021’’. 6 SEC. 2. IMPROVING HEALTH CARE COVERAGE UNDER VI- 7 SION AND DENTAL PLANS. 8 (a) PHSA.— 9 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 2 •S 1793 IS (1) IN GENERAL.—Part D of title XXVII of the 1 Public Health Service Act (42 U.S.C. 300gg–111 et 2 seq.) is amended by adding at the end the following: 3 ‘‘SEC. 2799A–11. IMPROVING COVERAGE UNDER VISION AND 4 DENTAL PLANS. 5 ‘‘(a) IN GENERAL.—Under a group health plan or in- 6 dividual or group health insurance coverage (including 7 such a plan or coverage offering limited scope dental or 8 vision benefits), the following shall apply: 9 ‘‘(1) PAYMENT AMOUNTS FROM COVERED PER- 10 SONS.— 11 ‘‘(A) IN GENERAL.—The plan or coverage 12 shall provide that, with respect to a doctor of 13 optometry, doctor of dental surgery, or doctor 14 of dental medicine that has an agreement to 15 participate in the plan or coverage and that 16 provides items or services that are not covered 17 services under the plan or coverage to a person 18 enrolled under such plan or coverage, the doctor 19 may charge the enrollee for such items or serv- 20 ices any amount determined by the doctor that 21 is equal to, or less than, the usual and cus- 22 tomary amount that the doctor charges individ- 23 uals who are not so enrolled for such items or 24 services. 25 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 3 •S 1793 IS ‘‘(B) ITEMS OR SERVICES CONSIDERED 1 COVERED BY A PLAN.—For purposes of sub- 2 paragraph (A), an item or service shall be con- 3 sidered, with respect to a plan or coverage, to 4 be covered services under the plan or coverage 5 only if the item or service is an item or service 6 with respect to which the plan or coverage is 7 obligated to pay an amount that is reasonable 8 and is not nominal or de minimis. 9 ‘‘(C) EXCEPTION FOR DENTAL CLEAN- 10 ING.—For purposes of subparagraph (A), a 11 doctor of dental surgery or doctor of dental 12 medicine that has an agreement to participate 13 in the plan or coverage may charge an enrollee 14 only the contracted network fee for any dental 15 cleaning, including any dental cleaning that ex- 16 ceeds the annual maximum under the enrollee’s 17 plan or coverage. 18 ‘‘(2) DURATION OF LIMITED SCOPE VISION AND 19 DENTAL PLANS.—In the case of an agreement be- 20 tween such a doctor and such a plan or coverage 21 that offers limited scope dental or vision benefits— 22 ‘‘(A) the agreement may be extended for a 23 term longer than 2 years only with the prior ac- 24 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 4 •S 1793 IS ceptance of the doctor for each such term ex- 1 tension; and 2 ‘‘(B) the agreement may be extended for 3 unlimited terms, subject to subparagraph (A). 4 ‘‘(3) NO RESTRICTIONS ON CHOICE OF LABORA- 5 TORIES.—The plan or coverage may not, directly or 6 indirectly, restrict or limit, such a doctor’s choice of 7 laboratories or choice of source and suppliers of 8 services or materials provided by the doctor to an in- 9 dividual who is enrolled under the plan or coverage. 10 ‘‘(b) PRIVATE RIGHT OF ACTION.—In addition to 11 any other remedies under State or Federal law, a person 12 adversely affected by a violation of this subsection may 13 bring action for injunctive relief against a plan described 14 in subsection (a) and, upon prevailing, in addition to such 15 injunctive relief shall recover monetary damages of no 16 more than $1,000 for each day found to be in violation 17 plus attorney’s fees and costs. The district courts of the 18 United States shall have exclusive jurisdiction of civil ac- 19 tions brought under this subsection. 20 ‘‘(c) RELATIONSHIP TO EXCEPTION FOR LIMITED, 21 EXCEPTED BENEFITS.—Section 2722(c)(1) shall not 22 apply with respect to the requirements of this section. 23 ‘‘(d) ELECTION TO BE EXCLUDED.— 24 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 5 •S 1793 IS ‘‘(1) IN GENERAL.—If a doctor of optometry, 1 doctor of dental surgery, or doctor of dental medi- 2 cine to which the provisions of paragraphs (1) and 3 (3) of subsection (a) otherwise apply makes an elec- 4 tion under this paragraph (in such form and manner 5 as the Secretary may by regulations prescribe), the 6 requirements of such paragraphs insofar as they 7 apply directly to the plan or coverage shall not apply 8 to such plan or coverage for such period, as de- 9 scribed in paragraph (2). 10 ‘‘(2) PERIOD OF ELECTION.—An election under 11 paragraph (1)— 12 ‘‘(A) shall apply for a single specified plan 13 year; 14 ‘‘(B) may be extended through subsequent 15 elections under this subsection; and 16 ‘‘(C) shall not be available with respect to 17 the requirements concerning the duration of 18 limited scope vision and dental plans under sub- 19 section (a)(2). 20 ‘‘(e) DEFINITIONS.—In this section: 21 ‘‘(1) The term ‘covered services’ means dental 22 care or vision care services for which reimbursement 23 is available under a plan or coverage contract, or for 24 which reimbursement would be available but for the 25 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 6 •S 1793 IS application of contractual limitations, including 1 deductibles, copayments, coinsurance, waiting peri- 2 ods, lifetime maximum, frequency limitations, and 3 alternative benefit payments. 4 ‘‘(2) The terms ‘doctor of dental surgery’ and 5 ‘doctor of dental medicine’ mean a doctor of dental 6 surgery or of dental medicine, as applicable, who is 7 legally authorized to practice dentistry by the State 8 in which the doctor performs such function and who 9 is acting within the scope of the license of the doctor 10 when performing such functions. 11 ‘‘(3) The term ‘doctor of optometry’ means a 12 doctor of optometry who is legally authorized to 13 practice optometry by the State in which the doctor 14 so practices.’’. 15 (2) CONFORMING AMENDMENT.—Section 16 2722(c)(1) of the Public Health Service Act (42 17 U.S.C. 300gg–21(c)(1)) is amended by striking 18 ‘‘The requirements’’ and inserting ‘‘Subject to sec- 19 tion 2799A–11, the requirements’’. 20 (b) ERISA.— 21 (1) IN GENERAL.—Subpart B of part 7 of sub- 22 title B of title I of the Employee Retirement Income 23 Security Act of 1974 (29 U.S.C. 1185 et seq.) is 24 amended by adding at the end the following: 25 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 7 •S 1793 IS ‘‘SEC. 726. IMPROVING COVERAGE UNDER VISION AND DEN- 1 TAL PLANS. 2 ‘‘(a) IN GENERAL.—Under a group health plan or 3 group health insurance coverage (including such a plan or 4 coverage offering limited scope dental or vision benefits), 5 the following shall apply: 6 ‘‘(1) PAYMENT AMOUNTS FROM COVERED PER- 7 SONS.— 8 ‘‘(A) IN GENERAL.—The plan or coverage 9 shall provide that, with respect to a doctor of 10 optometry, doctor of dental surgery, or doctor 11 of dental medicine that has an agreement to 12 participate in the plan or coverage and that 13 provides items or services that are not covered 14 services under the plan or coverage to a person 15 enrolled under such plan or coverage, the doctor 16 may charge the enrollee for such items or serv- 17 ices any amount determined by the doctor that 18 is equal to, or less than, the usual and cus- 19 tomary amount that the doctor charges individ- 20 uals who are not so enrolled for such items or 21 services. 22 ‘‘(B) ITEMS OR SERVICES CONSIDERED 23 COVERED BY A PLAN.—For purposes of sub- 24 paragraph (A), an item or service shall be con- 25 sidered, with respect to a plan or coverage, to 26 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 8 •S 1793 IS be covered services under the plan or coverage 1 only if the item or service is an item or service 2 with respect to which the plan or coverage is 3 obligated to pay an amount that is reasonable 4 and is not nominal or de minimis. 5 ‘‘(C) EXCEPTION FOR DENTAL CLEAN- 6 ING.—For purposes of subparagraph (A), a 7 doctor of dental surgery or doctor of dental 8 medicine that has an agreement to participate 9 in the plan or coverage may charge an enrollee 10 only the contracted network fee for any dental 11 cleaning, including any dental cleaning that ex- 12 ceeds the annual maximum under the enrollee’s 13 plan or coverage. 14 ‘‘(2) DURATION OF LIMITED SCOPE VISION AND 15 DENTAL PLANS.—In the case of an agreement be- 16 tween such a doctor and such a plan or coverage 17 that offers limited scope dental or vision benefits— 18 ‘‘(A) the agreement may be extended for a 19 term longer than 2 years only with the prior ac- 20 ceptance of the doctor for each such term ex- 21 tension; and 22 ‘‘(B) the agreement may be extended for 23 unlimited terms, subject to subparagraph (A). 24 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 9 •S 1793 IS ‘‘(3) NO RESTRICTIONS ON CHOICE OF LABORA- 1 TORIES.—The plan or coverage may not, directly or 2 indirectly, restrict or limit, such a doctor’s choice of 3 laboratories or choice of source and suppliers of 4 services or materials provided by the doctor to an in- 5 dividual who is enrolled under the plan or coverage. 6 ‘‘(b) PRIVATE RIGHT OF ACTION.—In addition to 7 any other remedies under State or Federal law, a person 8 adversely affected by a violation of this subsection may 9 bring action for injunctive relief against a plan described 10 in subsection (a) and, upon prevailing, in addition to such 11 injunctive relief shall recover monetary damages of no 12 more than $1,000 for each day found to be in violation 13 plus attorney’s fees and costs. The district courts of the 14 United States shall have exclusive jurisdiction of civil ac- 15 tions brought under this subsection. 16 ‘‘(c) RELATIONSHIP TO EXCEPTION FOR LIMITED, 17 EXCEPTED BENEFITS.—Section 732(c)(1) shall not apply 18 with respect to the requirements of this section. 19 ‘‘(d) ELECTION TO BE EXCLUDED.— 20 ‘‘(1) IN GENERAL.—If a doctor of optometry, 21 doctor of dental surgery, or doctor of dental medi- 22 cine to which the provisions of paragraphs (1) and 23 (3) of subsection (a) otherwise apply makes an elec- 24 tion under this paragraph (in such form and manner 25 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 10 •S 1793 IS as the Secretary may by regulations prescribe), the 1 requirements of such paragraphs insofar as they 2 apply directly to the plan or coverage shall not apply 3 to such plan or coverage for such period, as de- 4 scribed in paragraph (2). 5 ‘‘(2) PERIOD OF ELECTION.—An election under 6 paragraph (1)— 7 ‘‘(A) shall apply for a single specified plan 8 year; 9 ‘‘(B) may be extended through subsequent 10 elections under this subsection; and 11 ‘‘(C) shall not be available with respect to 12 the requirements concerning the duration of 13 limited scope vision and dental plans under sub- 14 section (a)(2). 15 ‘‘(e) DEFINITIONS.—In this section: 16 ‘‘(1) The term ‘covered services’ means dental 17 care or vision care services for which reimbursement 18 is available under a plan or coverage contract, or for 19 which reimbursement would be available but for the 20 application of contractual limitations, including 21 deductibles, copayments, coinsurance, waiting peri- 22 ods, lifetime maximum, frequency limitations, and 23 alternative benefit payments. 24 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 11 •S 1793 IS ‘‘(2) The terms ‘doctor of dental surgery’ and 1 ‘doctor of dental medicine’ mean a doctor of dental 2 surgery or of dental medicine, as applicable, who is 3 legally authorized to practice dentistry by the State 4 in which the doctor performs such function and who 5 is acting within the scope of the license of the doctor 6 when performing such functions. 7 ‘‘(3) The term ‘doctor of optometry’ means a 8 doctor of optometry who is legally authorized to 9 practice optometry by the State in which the doctor 10 so practices.’’. 11 (2) CONFORMING AMENDMENT.—Section 12 732(c)(1) of the Employee Retirement Income Secu- 13 rity Act of 1974 (29 U.S.C. 1191a(c)(1)) is amend- 14 ed by striking ‘‘The requirements’’ and inserting 15 ‘‘Subject to section 726, the requirements’’. 16 (3) CLERICAL AMENDMENT.—The table of con- 17 tents in section 1 of the Employee Retirement In- 18 come Security Act of 1974 (29 U.S.C. 1001 et seq.) 19 is amended by inserting after the item relating to 20 section 725 the following: 21 ‘‘Sec. 726. Improving coverage under vision and dental plans.’’. (c) IRC.— 22 (1) IN GENERAL.—Subchapter B of chapter 23 100 of the Internal Revenue Code of 1986 is amend- 24 ed by adding at the end the following: 25 VerDate Sep 11 2014 19:42 Jun 10, 2021 Jkt 019200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1793.IS S1793 pamtmann on DSKBC07HB2PROD with BILLS 12 •S 1793 IS ‘‘SEC. 9826. IMPROVING COVERAGE UNDER VISION AND 1 DENTAL PLANS. 2 ‘‘(a) IN GENERAL.—Under a group health plan (in- 3 cluding such a plan offering limited scope dental or vision 4 benefits), the following shall apply: 5 ‘‘(1) PAYMENT AMOUNTS FROM COVERED PER- 6 SONS.— 7 ‘‘(A) IN GENERAL.—The plan shall provide 8 that, with respect to a doctor of optometry, doc- 9 t [Text truncated for display. Full text available on Congress.gov.]