What This Bill Does
This bill amends federal health insurance laws to improve how dental and vision plans cover care. It sets rules about what patients pay for uncovered services and restricts how insurance companies can control which labs and suppliers dentists and eye doctors use.
##
Who It Affects
- People enrolled in group health insurance plans
- People with individual health insurance plans
- Dentists and optometrists who participate in insurance networks
- Health insurance companies
- State government agencies that oversee insurance
##
Key Provisions
- Dentists and eye doctors in insurance networks can charge patients for uncovered services (like cosmetic work) up to their normal fee for non-insured patients, except for dental cleanings which must use the contracted network price (Sec. 2719B(a)(1))
- Insurance plans cannot stop dentists and eye doctors from choosing their own laboratories or suppliers for patient care (Sec. 2719B(a)(3))
- Agreements between dentists/eye doctors and limited scope vision or dental plans can only extend beyond 2 years if the doctor agrees each time, but can be renewed indefinitely (Sec. 2719B(a)(2))
- The federal government must notify states annually of their authority to enforce these rules and take action if states do not comply within 90 days (Sec. 2719B(b))
- Dentists and eye doctors can choose to opt out of these requirements for one plan year at a time (Sec. 2719B(d))
##
What Changes
If passed, health insurance plans must follow new rules when dentists and eye doctors are in their networks. Insurance companies lose the power to restrict which labs and suppliers these doctors use. Patients will see a clear distinction between covered dental and vision services and uncovered services, with transparent pricing for the uncovered ones (except dental cleanings, which stay at negotiated rates).
##
Important Definitions
- **Covered services**: Dental or vision care services where the insurance plan will pay money back, or would pay back except for limits like deductibles (upfront costs you pay) or copayments (set fees you pay per visit)
- **Doctor of dental surgery or dental medicine**: A dentist licensed by their state to practice dentistry and acting within the scope of that license (the legal boundaries of their work)
- **Doctor of optometry**: An eye doctor licensed by their state to practice optometry (eye care and vision testing)
##
Effective Date
Not specified in bill text
I
118TH CONGRESS
1ST SESSION H. R. 1385
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 HOUSE OF REPRESENTATIVES
MARCH 7, 2023
Mr. CARTER of Georgia (for himself, Ms. CLARKE of New York, and Mr. SES-
SIONS) introduced the following bill; which was referred to the Committee
on Energy and Commerce
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 2023’’ or the ‘‘DOC Access Act of
5
2023’’.
6
VerDate Sep 11 2014
22:01 Mar 20, 2023
Jkt 039200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H1385.IH
H1385
kjohnson on DSK79L0C42PROD with BILLS
2
•HR 1385 IH
SEC. 2. IMPROVING HEALTH CARE COVERAGE UNDER VI-
1
SION AND DENTAL PLANS.
2
(a) IN GENERAL.—Title XXVII of the Public Health
3
Service Act is amended by inserting after section 2719A
4
(42 U.S.C. 300gg–19a) the following new section:
5
‘‘SEC. 2719B. IMPROVING COVERAGE UNDER VISION AND
6
DENTAL PLANS.
7
‘‘(a) IN GENERAL.—Under a group health plan or in-
8
dividual or group health insurance coverage (including
9
such a plan or coverage offering limited scope dental or
10
vision benefits), the following shall apply:
11
‘‘(1) PAYMENT AMOUNTS FROM COVERED PER-
12
SONS.—
13
‘‘(A) IN GENERAL.—The plan or coverage
14
shall provide that, with respect to a doctor of
15
optometry, doctor of dental surgery, or doctor
16
of dental medicine that has an agreement to
17
participate in the plan or coverage and that
18
provides items or services that are not covered
19
services under the plan or coverage to a person
20
enrolled under such plan or coverage, the doctor
21
may charge the enrollee for such items or serv-
22
ices any amount determined by the doctor that
23
is equal to, or less than, the usual and cus-
24
tomary amount that the doctor charges individ-
25
VerDate Sep 11 2014
22:01 Mar 20, 2023
Jkt 039200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H1385.IH
H1385
kjohnson on DSK79L0C42PROD with BILLS
3
•HR 1385 IH
uals who are not so enrolled for such items or
1
services.
2
‘‘(B) ITEMS
OR
SERVICES
CONSIDERED
3
COVERED BY A PLAN.—For purposes of sub-
4
paragraph (A), an item or service shall be con-
5
sidered, with respect to a plan or coverage, to
6
be covered services under the plan or coverage
7
only if the item or service is an item or service
8
with respect to which the plan or coverage is
9
obligated to pay an amount that is reasonable
10
and is not nominal or de minimis.
11
‘‘(C) EXCEPTION
FOR
DENTAL
CLEAN-
12
ING.—For purposes of subparagraph (A), a
13
doctor of dental surgery or doctor of dental
14
medicine that has an agreement to participate
15
in the plan or coverage may charge an enrollee
16
only the contracted network fee for any dental
17
cleaning, including any dental cleaning that ex-
18
ceeds the annual maximum under the enrollee’s
19
plan or coverage.
20
‘‘(2) DURATION OF LIMITED SCOPE VISION AND
21
DENTAL PLANS.—In the case of an agreement be-
22
tween such a doctor and such a plan or coverage
23
that offers limited scope dental or vision benefits—
24
VerDate Sep 11 2014
22:01 Mar 20, 2023
Jkt 039200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H1385.IH
H1385
kjohnson on DSK79L0C42PROD with BILLS
4
•HR 1385 IH
‘‘(A) the agreement may be extended for a
1
term longer than 2 years only with the prior ac-
2
ceptance of the doctor for each such term ex-
3
tension; and
4
‘‘(B) the agreement may be extended for
5
unlimited terms, subject to subparagraph (A).
6
‘‘(3) NO RESTRICTIONS ON CHOICE OF LABORA-
7
TORIES.—The plan or coverage may not, directly or
8
indirectly, restrict or limit, such a doctor’s choice of
9
laboratories or choice of source and suppliers of
10
services or materials provided by the doctor to an in-
11
dividual who is enrolled under the plan or coverage.
12
‘‘(b) NOTIFICATION.—The Secretary shall on an an-
13
nual basis notify each State of the State’s authority to
14
enforce the provisions of subsection (a) against a group
15
health plan or health insurance coverage described in sub-
16
section (a) pursuant to section 2723(a)(1) and request
17
confirmation from the State whether or not the State will
18
enforce the provisions of subsection (a). If a State notifies
19
the Secretary that the State will not enforce the provisions
20
of subsection (a) or fails to respond within 90 days of the
21
Secretary’s request, the Secretary shall treat such State
22
as failing to substantially enforce such provisions for pur-
23
poses of subsections (a)(2) and (b) of section 2723.
24
VerDate Sep 11 2014
22:01 Mar 20, 2023
Jkt 039200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H1385.IH
H1385
kjohnson on DSK79L0C42PROD with BILLS
5
•HR 1385 IH
‘‘(c) RELATIONSHIP TO EXCEPTION FOR LIMITED,
1
EXCEPTED
BENEFITS.—Section 2722(c)(1) shall not
2
apply with respect to the requirements of this section.
3
‘‘(d) ELECTION TO BE EXCLUDED.—
4
‘‘(1) IN GENERAL.—If a doctor of optometry,
5
doctor of dental surgery, or doctor of dental medi-
6
cine to which the provisions of paragraphs (1) and
7
(3) of subsection (a) otherwise apply makes an elec-
8
tion under this paragraph (in such form and manner
9
as the Secretary may by regulations prescribe), the
10
requirements of such paragraphs insofar as they
11
apply directly to the plan or coverage shall not apply
12
to such plan or coverage for such period, as de-
13
scribed in paragraph (2).
14
‘‘(2) PERIOD OF ELECTION.—An election under
15
paragraph (1)—
16
‘‘(A) shall apply for a single specified plan
17
year;
18
‘‘(B) may be extended through subsequent
19
elections under this subsection; and
20
‘‘(C) shall not be available with respect to
21
the requirements concerning the duration of
22
limited scope vision and dental plans under sub-
23
section (a)(2).
24
‘‘(e) DEFINITIONS.—In this section:
25
VerDate Sep 11 2014
22:01 Mar 20, 2023
Jkt 039200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H1385.IH
H1385
kjohnson on DSK79L0C42PROD with BILLS
6
•HR 1385 IH
‘‘(1) The term ‘covered services’ means dental
1
care or vision care services for which reimbursement
2
is available under a plan or coverage contract, or for
3
which reimbursement would be available but for the
4
application of contractual limitations, including
5
deductibles, copayments, coinsurance, waiting peri-
6
ods, lifetime maximum, frequency limitations, and
7
alternative benefit payments.
8
‘‘(2) The terms ‘doctor of dental surgery’ and
9
‘doctor of dental medicine’ mean a doctor of dental
10
surgery or of dental medicine, as applicable, who is
11
legally authorized to practice dentistry by the State
12
in which the doctor performs such function and who
13
is acting within the scope of the license of the doctor
14
when performing such functions.
15
‘‘(3) The term ‘doctor of optometry’ means a
16
doctor of optometry who is legally authorized to
17
practice optometry by the State in which the doctor
18
so practices.’’.
19
(b) CONFORMING AMENDMENT.—Section 2722(c)(1)
20
of the Public Health Service Act (42 U.S.C. 300gg–
21
21(c)(1)) is amended by striking ‘‘The requirements’’ and
22
inserting ‘‘Subject to section 2719B, the requirements’’.
23
(c) EXCLUSIVE APPLICABILITY OF STATE LAW.—
24
Notwithstanding any amendment made by this Act, State
25
VerDate Sep 11 2014
22:01 Mar 20, 2023
Jkt 039200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H1385.IH
H1385
kjohnson on DSK79L0C42PROD with BILLS
7
•HR 1385 IH
law that directly affects any standard or requirement re-
1
lating to health insurance issuers and dental or vision ben-
2
efit plans, shall have exclusive application and the amend-
3
ments made by this Act shall not apply to the extent that
4
such State law conflicts with such amendments. The State
5
shall retain exclusive jurisdiction over health insurance
6
issuers and limited scope dental or vision benefit plans
7
that are directly governed by such State.
8
Æ
VerDate Sep 11 2014
22:01 Mar 20, 2023
Jkt 039200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6301
E:\BILLS\H1385.IH
H1385
kjohnson on DSK79L0C42PROD with BILLS