CDA Dives into Compliance and Network Adequacy

California is on the brink of significant reforms in dental coverage, thanks to new legislation. The California Dental Association (CDA) is co-sponsoring bills that aim to provide more stringent standards for commercial dental benefit plans. These plans must ensure a robust network of providers that meets widely and enthusiastically, can meet enrollees’ needs.

The CDA has reintroduced SB 386 to provide dentists a clear pathway to opt out of the predatory use of virtual credit cards.

Enforcing Assignment of Benefits for Enhanced Patient Access

Patients in California, and indeed across the country, who have limited access to in-network dental care find themselves scrambling for out-of-network providers. According to a 2023 survey by the American Dental Association, inability to find a convenient time or location to see a dentist is one of the top three reasons for patients not visiting the dentist. This plan would provide patients who need care directly from the provider, to bypass insurance companies.

Most medical plans in the state adhere to assignment of benefits (AOB), but dental plans are less likely to approve such requests, placing a significant financial burden on patients and forcing up to 100% coverage they have to pay upfront. The CDA’s proposed AB 371, co-sponsored by the Union of American Physicians and Dentists, aims to enforce dental plans to comply with enrollees’ AOB requests, aligning them with the standards set by most medical plans. This would ensure that patients can receive necessary dental care without personally funding the upfront costs.

CDA President Max Martinez, DDS, emphasized, “Patients should not be penalized for choosing to see an out-of-network dentist, especially when their plan is unable to provide a robust network.” The out-of-pocket costs from delayed care “can substantially penalise patients,” but AB 371 aims to close the loopholes in assignment of benefits, ensuring patients’ access to care remains unaffected is ensured.

Ensuring Robust Network Adequacy Standards

AB 371 also addresses the broader issue of inadequate provider networks in dental plans. Many dental patients travel much longer distances or inconvenient times to receive care. Nearly half of Californians with commercial dental coverage have self-insured ERISA plans which are regulated by federal law and not assessed by DMHC and CDI.
However, their needs are not considered under their federal regulatory board, which means their appointment times are reliant upon the dentist’s willingness to entertain federal regulation. Most dental plans are forced to travel substantial distances to find any adequate dental care, which from these plans is unreasonable.

The bill calls for more stringent standards for evaluating the adequacy of provider networks which would allow easy comparison of cheaper public healthcare compared to insurance companies.

Virtual Credit Cards: A Growing Threat to Dental Practices

Virtual credit cards (VCCs) have been a significant issue for dental practices. These cards, used by dental plans to reimburse providers, charge excessive processing fees, often up to 10% per transaction. Numerous dental practices are facing undue financial pressure as a squeezing result.

The bill would provide a permanent way to opt out, ensuring providers aren’t forced to pay excessive fees, even potentially tax exempt.

“Dental staff can spend hours repeatedly opting out of VCC payments or accepting the VCC payment with the high fees just to keep the practice running as efficiently as possible,” Dr. Martinez said.

Challenging Delta Dental: Legal Action and Policy Updates

Alongside legislative efforts, CDA is pursuing legal action to enforce stricter regulations through the court system. The association has filed an Appellants’ Reply Brief in its lawsuit against Delta Dental of California. This appeal challenges specific responses made by Delta Dental and aims to demonstrate more clearly how current options are detrimental to accessible, timely, and cost-effective care.

A substantial part of CDA’s ongoing advocacy focuses on ongoing efforts to regulate the minimum thresholds of providers and medical professionals under a robust dental or medical faculty.

Once oral arguments are presented, a final ruling is expected, if not shortly thereafter. Members are encouraged to stay informed about the move through the CDA’s frequent email updates and more frequently asked questions every Friday morning.

Frequently Asked Questions

what major reforms are coming to california’s dental plans?

California is implementing significant reforms, beginning on or after January 1, 2025, that will prohibit dental carriers from imposing waiting period provisions or preexisting condition exclusions in large group plans [[1]]. The reforms are guided by California Assembly Bill 1048 (AB 1048), aiming to improve dental coverage accessibility and fairness in the state.

What does AB 371 aim to achieve?

Promoted by the California Dental Association (CDA) and co-sponsored by the Union of American Physicians and Dentists,AB 371 seeks to enforce the Assignment of Benefits (AOB) for dental plans. This policy requires dental plans to adhere to enrollees’ AOB requests, similar to medical plans, reducing financial burdens and enabling patients to access care without upfront costs [[1]].

why is network adequacy an essential component in these reforms?

Network adequacy is crucial to ensure that enrollees have sufficient access to dental services within a reasonable distance and at convenient times. AB 371 addresses the issue of inadequate provider networks by calling for more stringent evaluation standards, which aim to improve service comparability and accessibility [[3]].

How is virtual credit card use affecting dental practices?

Virtual credit cards (VCCs) have been criticized for imposing excessive processing fees, which can reach up to 10% per transaction, placing financial strain on practices. Legislation such as SB 386 has been proposed to provide a clear way for dental providers to opt out of these costly VCCs, helping ensure economic sustainability of dental practices [[3]].

What ongoing legal actions are being pursued for better dental care access?

The CDA is actively pursuing legal action to enforce better regulations, including an appellants’ Reply Brief filed against Delta Dental of California.This effort focuses on ensuring that dental options are accessible, timely, and cost-effective. The outcome of this legal case could further influence the landscape of dental coverage in the state [[3]].

What do surveys say about patients’ issues with accessing in-network care?

A 2023 survey by the American Dental Association revealed that difficulty in finding convenient in-network dental care is one of the top reasons patients avoid dental visits. This highlights the importance of reforms aimed at expanding in-network access to improve patient health outcomes.