RS 22:1154

§1154. Freedom of choice of dentist in health plans A. As used in this Section: (1) "Dental care services" means any services furnished to any person for the purpose of preventing, alleviating, curing or healing human dental abnormalities, accidents, or diseases. (2) "Dentist" means any person who furnishes dental care services and who is licensed as a dentist by the state of Louisiana. (3) "Employee benefit plan" means any plan, fund, or program heretofore or hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, dental care benefits in the event of abnormality, accident, or dental disease. (4) "Health insurance policy" means any individual, group, blanket, or association insurance policy, insurance agreement, or group hospital service contract providing benefits for dental care expenses incurred as a result of an abnormality, accident, or dental disease. B.(1) No health insurance policy or employee benefit plan which is delivered, renewed, issued for delivery, or otherwise contracted for in this state shall: (a) Prevent any person who is a party to or beneficiary of any such health insurance policy or employee benefit plan from selecting the dentist of his choice to furnish the dental care services offered by the policy or plan, or interfere with such selection. (b) Deny any dentist the right to participate as a contracting provider for such policy or plan. (c) Authorize any person to regulate, interfere, or intervene in any manner in the diagnosis or treatment rendered by a dentist to his patient. (d) Require that any dentist make or obtain dental x-rays or any other diagnostic aids; however, nothing herein shall prohibit requests for existing dental x-rays or any other existing diagnostic aids for the purpose of determining benefits payable under a health insurance policy or employee benefit plan. (2) Nothing herein shall prohibit the predetermination of benefits for dental care expenses prior to treatment by the attending dentist. C. Any health insurance policy or employee benefit plan which is delivered, renewed, issued for delivery, or otherwise contracted for in this state, to the extent that it provides benefits for dental care expenses, shall: (1) Disclose, if applicable, that the benefit offered is limited to the least costly treatment. (2)(a) Define and explain the standard upon which the payment of benefits or reimbursement for the cost of dental care services is based, such as "usual and customary", "reasonable and customary", "usual customary and reasonable" fees or words of similar import, or shall specify in dollars and cents the amount of the payment or reimbursement for dental care services to be provided. (b) The payment or reimbursement for a noncontracting provider dentist shall be the same as or greater than the payment or reimbursement for a contracting provider dentist; however, the health insurance policy or the employee benefit plan shall not be required to make payment or reimbursement in an amount that is greater than the amount so specified in the policy or plan or that is greater than the fee charged by the providing dentist for the dental care services rendered. D. Any provision in a health insurance policy or employee benefit plan which is delivered, renewed, issued for delivery, or otherwise contracted for in this state which is contrary to this Section shall, to the extent of such conflict, be void. E. The provisions of this Section shall not be deemed to mandate that any type of benefits for dental care expenses be provided by a health insurance policy or an employee benefit plan. F. Notwithstanding any other provision of this Section: (1) A dentist or a professional dental corporation as authorized under the provisions of R.S. 12:981, et seq. may contract directly with a patient for the furnishing of dental care services to the patient as may be otherwise authorized by law. (2) Any person providing a health insurance policy or employee benefit plan, any employer, or any employee organization may: (a) Make available to its insureds, beneficiaries, participants, employees, or members information relating to dental care services by the distribution of factually accurate information regarding dental care services, rates, fees, location, and hours of service, provided such distribution is made upon the request of any dentist licensed by this state. (b) Establish an administrative mechanism which facilitates payment for dental care services by insureds, beneficiaries, participants, employees, or members to the dentist of their choice. (c) Pay or reimburse, on a nondiscriminatory basis, its insureds, beneficiaries, participants, employees, or members for the cost of dental care services rendered by the dentist of their choice. G. The provisions of this Section shall not apply to health insurance policies and employee benefit plans issued before July 12, 1985. Acts 1985, No. 441, §1, July 12, 1985; Acts 2003, No. 129, §1, eff. May 28, 2003; Acts 2004, No. 607, §1; Redesignated from R.S. 22:1513 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009.