632.873 Restrictions relating to fees for dental services.

(1) Definitions. In this section, unless the context requires otherwise:

(a) “Covered service" means, with respect to dental or related services specified in a policy or plan that provides coverage for those services, a service provided by a dentist or at the direction of a dentist to an insured under the policy or an enrollee of the plan for which the policy or plan makes payment, administered consistently with policies traditionally governing covered services, or for which the policy or plan would make payment but for the application of contractual limitations of deductibles, copayments, coinsurance, waiting periods, annual maximums, lifetime maximums applicable to the same course of treatment, frequency limitations, or alternative benefit payments.

(b) “Policy" means a policy, certificate, or contract of insurance that provides only limited-scope dental benefits.

(c) “Related service" means a service that is commonly provided, by a dentist or at the direction of a dentist, in conjunction with a dental service.

(2) Prohibitions on setting fees.

(a)

1. A contract between an insurer offering a policy that provides coverage for dental and related services and a dentist for the provision of dental and related services to an insured under the policy may not require the dentist to provide a service to an insured under the policy at a fee set by the insurer unless the service is a covered service under the policy.

2. A policy that provides coverage for dental and related services may not provide nominal or de minimis coverage for a dental or related service for the sole purpose of avoiding the requirements under subd. 1.

(b) An administrator providing 3rd-party administration services or a provider network for a plan that provides coverage for dental and related services may not require any dentist in the administrator's provider network that is eligible to provide services under the plan to charge set fees for dental or related services provided to enrollees of the plan that are not covered services under the plan.

(3) Prohibition on charges. A dentist who, under a contract with an insurer offering a policy that provides coverage for dental and related services, provides dental or related services to an insured under the policy may not charge the insured more than the dentist's usual nondiscounted fee for a dental or related service that is not a covered service under the policy.

History: 2013 a. 26.