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Chapter 04. Dental Plans — General Provisions

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Regulation .01 Purpose.Copy Citation

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The purpose of this chapter is to provide appropriate standards and requirements for dental plan contracts.

Regulation .02 Definitions.Copy Citation

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A.
In this chapter, the following terms have the meanings indicated.
B.
Terms Defined.
(1)
“Closed panel dental benefit contract” means a dental benefit contract that does not provide benefits for services provided by a dentist who is not a plan dentist, with the exception of:
(a)
Emergency services; and
(b)
Out-of-network services required by Insurance Article, §15-830, Annotated Code of Maryland.
(2)
“Contract holder” means for:
(a)
Group contracts, the organization or entity to which the contract is issued;
(b)
Individual contracts, the person who applies for a contract covering:
(i)
One individual, or
(ii)
One individual and that individual's dependents.
(3)
“Copayment” means the amount:
(a)
Payable for a particular service by an enrollee in accordance with the patient charge schedule; or
(b)
For which the enrollee is responsible as a condition for receiving benefits under a dental benefit contract.
(4)
“Dental benefit contract” means a contract which provides benefits for dental services entered into between the dental plan organization and:
(a)
An individual contract holder covering the:
(i)
Subscriber;
(ii)
Subscriber and the subscriber’s dependents;
(iii)
Subscriber and the subscriber’s family members;
(iv)
Subscriber’s dependent or dependents; or
(v)
Subscriber and the subscriber’s dependents and family members; or
(b)
The group contract holder covering the:
(i)
Enrolled members of the group;
(ii)
Enrolled members of the group and their dependents;
(iii)
Enrolled members of the group and their family members; or
(iv)
Enrolled members of the group and their dependents and family members.
(5)
“Dental plan” means any contractual arrangement for dental services.
(6)
“Dental plan organization” means a:
(a)
Person that provides directly, arranges for, or administers a dental plan on a prepaid or postpaid individual or group capitation basis; or
(b)
Nonprofit health service plan which limits its operation to providing directly, or arranging for or administering a plan providing, dental services.
(7)
“Dental service” has the meaning stated in Insurance Article, §14-401, Annotated Code of Maryland.
(8)
“Dependent” means an individual who is the spouse or child of a subscriber.
(9)
“Enrollee” means a subscriber, or any dependent of the subscriber, who is enrolled in the dental plan organization.
(10)
“Evidence of coverage” means any certificate, agreement, or contract issued to a subscriber of a group that sets out the dental services to which the enrollees are entitled.
(11)
“Patient charge schedule” means a list of amounts which the enrollee is required to pay the plan dentist or the dental plan organization for particular services rendered under the dental benefit contract.
(12)
“Plan dentist” means any dentist who has contracted with the dental plan organization or with an entity acting on behalf of the dental plan organization to provide dental services to the enrollees.
(13)
“Provider contract” means a contract between the dental plan organization or an entity acting on behalf of the dental plan organization and a plan dentist.
(14)
“Subscriber” means, for:
(a)
Group dental benefit contracts, the person who is eligible to be covered under the contract, other than as a dependent, by reason of satisfying the eligibility requirements of the group;
(b)
Individual dental benefit contracts, the individual who applies to the dental plan organization for coverage for:
(i)
That individual only;
(ii)
The individual and the individual’s dependents; or
(iii)
The individual’s dependent or dependents.

Regulation .03 Applicability.Copy Citation

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This chapter applies to:
A.
Dental plan organizations authorized under Insurance Article, Title 14, Subtitles 1 and 4, Annotated Code of Maryland; and
B.
Contracts issued or renewed by the dental plan organizations listed in §A of this regulation on or after the effective date of this chapter.

Regulation .04 Dental Benefit Contract.Copy Citation

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Each dental benefit contract shall contain the following provisions:
A.
The effective date of contract provision;
B.
A provision describing the payment of required subscription fees or premiums;
C.
A grace period provision, pursuant to Regulation .05 of this chapter;
D.
For group dental benefit contracts, the eligibility requirements and effective date of coverage for members of the group and their dependents;
E.
A provision describing the benefits available under the contract;
F.
A provision describing the copayments for which the enrollee is responsible;
G.
A provision describing the service area, if applicable;
H.
If a dental plan organization generally provides benefits only within a stated service area, a provision providing for emergency dental services outside the service area, with the term “emergency” including care to alleviate acute pain;
I.
For closed panel dental benefit contracts:
(1)
A provision indicating that if a plan dentist refers the enrollee to a specialist who is not a plan dentist for dental services which are covered under the dental benefit contract, the dental plan organization shall be responsible for payment of the specialist’s charges to the extent the charges exceed the copayment specified in the dental benefit contract; and
(2)
A provision which reads substantially as follows: “If during the term of this contract none of the plan dentists can render necessary care and treatment to the enrollee due to circumstances not reasonably within the control of the dental plan organization, such as complete or partial destruction of facilities, war, riot, civil insurrection, labor disputes, or the disability of a significant number of the plan dentists, then the enrollee may seek treatment from an independent licensed dentist of the enrollee’s own choosing. The dental plan organization will pay the enrollee for the expenses incurred for the dental services with the following limitations: The dental plan organization will pay the enrollee for services which are listed in the patient charge schedule as No Charge, to the extent that such fees are reasonable and customary for dentists in the same geographic area; the dental plan organization will also pay the enrollee for those services listed in the contract for which there is a copayment, to the extent that the reasonable and customary fees for such services exceed the copayment for such services as set forth in the contract. The enrollee may be required to give written proof of loss. The dental plan organization agrees to be subject to the jurisdiction of the Maryland Insurance Commissioner in any determination of the impossibility of providing services by plan dentists.”;
J.
A provision setting out the terms under which coverage will terminate;
K.
A provision setting out a grievance procedure provision that complies with the requirements of Insurance Article, Title 15, Subtitle 10D, and as applicable, Subtitle 10A, Annotated Code of Maryland; and
L.
A provision setting out an extension of benefits in accordance with Insurance Article, §15-833, Annotated Code of Maryland.

Regulation .05 Grace Period Requirements.Copy Citation

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A.
Individual Dental Benefit Contracts.
(1)
If the individual dental benefit contract is guaranteed renewable for the life of the individual dental benefit contract, the dental benefit contract shall contain in substance the following provision: “Grace Period: A grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period this contract shall continue in force.”
(2)
If the individual dental benefit contract gives the dental plan organization the right to refuse renewal, the individual dental benefit contract shall contain in substance the following provision: “Grace Period: Unless at least 30 days before the premium due date the dental plan organization has delivered to the subscriber, or has mailed to the subscriber's last address as shown by the records of the dental plan organization, written notice of its intention not to renew this contract beyond the period for which the premium has been accepted, a grace period of 31 days will be granted for the payment of each premium falling due after the first premium, during which grace period this contract shall continue in force.”
B.
Group Dental Benefit Contracts.
(1)
Each group dental benefit contract shall contain in substance the following provision: “Grace Period: A grace period of 30 days will be granted for payment of each premium due after the first premium, unless the dental plan organization does not intend to renew the contract beyond the period for which premium has been accepted and notice of the intention not to renew is delivered to the contract holder at least 45 days before the premium is due. During the grace period the contract shall continue in force”.
(2)
Any additional provisions related to the grace period shall be expressly stated in the group dental benefit contract, subject to the following limitations:
(a)
Unless a dental plan organization receives a notice of the contract holder's intention to terminate the policy before the end of the grace period, the dental plan organization may collect premium for the 30-day grace period;
(b)
If a dental plan organization receives a notice of intention to terminate the group dental benefit contract during the grace period, the dental plan organization may collect premium for the period beginning on the first day of the grace period until the date on which notice is received or the date of termination stated in the notice, whichever is later; and
(c)
If premium for the 30-day grace period is paid after the grace period ends, a dental plan organization may charge interest for the premium for the group dental benefit contract, but:
(i)
Interest may not begin to accrue during the 30-day grace period; and
(ii)
The interest rate charged may not exceed an effective rate of 6 percent per year.

Regulation .06 Evidence of Coverage.Copy Citation

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A.
Except for Regulation .04A—C of this chapter, the evidence of coverage under any group contract shall contain all of the provisions required in Regulation .04 of this chapter.
B.
The name of the group shall be specified in the evidence of coverage.

Regulation .07 Optional Provisions.Copy Citation

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A.
Dental benefit contracts may contain the provisions in §§B—D of this regulation, and if any of the provisions are included in a group dental benefit contract, the same provision shall be contained in the corresponding evidence of coverage.
B.
General Provisions.
(1)
A provision may be included specifying the dental plan organization's intention to charge a specified missed appointment fee. The fee shall be reasonable in relation to the nature of the procedure for which the missed appointment had been made. Neither the plan dentist nor the dental plan organization may charge a missed appointment fee unless this provision appears in the dental benefit contract.
(2)
A provision may be included specifying the dental plan organization's ability to increase premiums or subscription fees, with this provision indicating that these fees may not be increased unless:
(a)
The contract holder has been given written notice at least 45 days before the effective date of the increase; and
(b)
In the case of:
(i)
An individual contract, present rates have not been changed for at least 12 months,
(ii)
A group contract, present rates under the contract have been in effect for at least 12 months.
(3)
A provision may be included specifying the dental plan organization's intention to impose a financial penalty on an enrollee for voluntarily withdrawing from the dental plan during the first year of coverage, which penalty may not:
(a)
Be charged if the enrollee withdraws from the dental plan after being covered for at least 12 months; or
(b)
Exceed the usual, customary, and reasonable charge for services received reduced by the sum of the subscription fees paid by or for the enrollee and any copayments paid by or for the enrollee.
(4)
A provision may be included specifying the dental plan organization's ability to increase the patient charge schedule, with the provision indicating that the increase may not be effective unless the:
(a)
Present schedule has been in effect for at least 12 months; and
(b)
Contract holder has been given written notice of the increase at least 30 days before the effective date of the increase.
(5)
A provision may be included specifying the dental plan organization's rights if an enrollee refuses to follow a particular course of treatment. The dental plan organization may not terminate the membership of an enrollee for refusal to follow an appropriate course of treatment for a particular condition. The provision may indicate that the dental plan organization may refuse to provide any further benefits for the particular condition if the enrollee refuses to accept the recommended course of treatment.
(6)
A provision may be included specifying the dental plan organization's rights if an enrollee fraudulently uses his membership card or knowingly permits his membership card to be used by others. The dental plan organization may terminate an enrollee's coverage if the enrollee fraudulently uses his membership card or knowingly permits his membership card to be used by others. The dental plan organization may not terminate coverage for an entire family because a dependent fraudulently uses the membership card. In this instance, only the dependent's coverage may terminate.
C.
Termination Provision. A provision may be included which specifies that the dental plan organization may terminate an enrollee's coverage if the enrollee is unable to maintain a satisfactory dentist-patient relationship with a plan dentist, with this provision:
(1)
Indicating that before terminating the enrollee's coverage, the dental plan organization shall permit the enrollee to change primary dentists at least once;
(2)
Specifying that the enrollee shall be given written notice of the termination at least 30 days before the termination of the enrollee's membership.
D.
Dependent Children Provision. If the contract provides coverage for dependent children, the contract shall also contain the following provision: “Notwithstanding any limiting age stated in the contract, any unmarried child covered under the contract as a dependent of an enrollee who is chiefly dependent for support upon the enrollee, and who, at the time of reaching the limiting age, is incapable of self-support because of mental or physical incapacity that commenced prior to the child's attaining the limiting age, shall continue to be covered under the contract while remaining so dependent, unmarried, and mentally or physically incapacitated, until the coverage on the enrollee upon whom the child is dependent terminates.”

Regulation .08 Provider Contracts.Copy Citation

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A.
Each provider contract shall contain the provisions in §§B—G of this regulation.
B.
A provision shall be included to require the provider to make an initial commitment to the plan of at least 12 months. The provider may not terminate the contract during this 12-month period unless the provider becomes unavailable during that initial time for reasons beyond the control of the dental plan organization or the provider.
C.
Hold-Harmless Clause. A hold-harmless clause, which shall read substantially as follows is required: “The provider agrees that under no circumstances, including nonpayment by the dental plan organization, insolvency of the dental plan organization, or breach of this contract, shall provider seek payment from an enrollee for services rendered under this contract for other than a copayment listed in the dental benefit contract. Provider further agrees that this provision shall survive the termination of this provider contract regardless of the cause of the termination.”
D.
A provision specifying when the contract becomes effective is required.
E.
A provision specifying the date the contract terminates is required.
F.
A renewal provision is required.
G.
A provision specifying the benefits the provider shall supply the enrollees is required, specifying that:
(1)
The provider shall supply services to enrollees in exchange for the copayments specified in the dental benefit contract while the provider's provider contract is in force; and
(2)
After the provider contract terminates, the provider shall continue to provide services to enrollees in accordance with Insurance Article, §15-112, Annotated Code of Maryland.

Regulation .09 Contract Forms.Copy Citation

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A.
The dental plan organization:
(1)
Shall provide a written dental benefit contract to each group contract holder;
(2)
Shall provide a written evidence of coverage to each individual covered under a group dental benefit contract;
(3)
Shall provide a written dental benefit contract to each individual who applies for individual dental coverage;
(4)
Shall execute a written provider contract with each of the dental plan organization's plan dentists;
(5)
May not deliver or issue for delivery in this State any of the following forms unless the form has been filed with and approved by the Insurance Commissioner:
(a)
Dental benefit contract,
(b)
Evidence of coverage,
(c)
Provider contract,
(d)
Application form, and
(e)
Riders or endorsement forms.
B.
The Commissioner shall disapprove any form filed, or withdraw any previous approval, if the form:
(1)
Contains or incorporates by reference, when the incorporation is otherwise permissible, any inconsistent, ambiguous, or misleading clauses, or exceptions and conditions which deceptively affect the risk purported to be assumed in the general coverage of the contract;
(2)
Has any title, heading, or other indication of its provisions which is likely to mislead the contract holder or individual;
(3)
Contains an inequitable provision or a provision without substantial benefit to the contract holder;
(4)
Is printed or otherwise reproduced in a manner as to render any provision of the form substantially illegible;
(5)
Includes benefit provisions which are unreasonable in relation to the premium or subscription fee charged; or
(6)
Is a provider contract which does not provide for the rendering of covered services in a reasonable manner.

Regulation .10 Filing Requirements for Premium Rates and Subscription Fees.Copy Citation

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A.
The filing of any dental plan contract or rider or endorsement by a dental plan organization in accordance with Regulation .09A(5) of this chapter shall be accompanied by the filing of premium rates or subscription fees.
B.
A subsequent change in premium rates or subscription fees shall be filed with supporting data at least 30 days before the change is proposed to become effective.
Chapter annotations
Authority: Insurance Article, §§2-109, 14-124(b), 14-410, 14-412, 15-112(b)(1)(i), 15-122(b), 15-833(j),
and Title 15, Subtitles 10A and 10D, Annotated Code of Maryland
History: Effective date: September 16, 1991 (18:18 Md. R. 2004)
History: Chapter recodified from COMAR 09.30.82 to COMAR 31.12.04 effective September 7, 1998 (25:18 Md. R. 1439)
History: Regulation .02B amended effective August 2, 2004 (31:15 Md. R. 1187); August 3, 2015 (42:15 Md. R. 1019)
History: Regulation .04 amended effective August 2, 2004 (31:15 Md. R. 1187); August 3, 2015 (42:15 Md. R. 1019)
History: Regulation .05 repealed and new Regulation .05 adopted effective August 2, 2004 (31:15 Md. R. 1187)
History: Regulation .06A amended effective August 2, 2004 (31:15 Md. R. 1187)
History: Regulation .07B amended effective August 2, 2004 (31:15 Md. R. 1187)
History: Regulation .08G amended effective August 2, 2004 (31:15 Md. R. 1187)