reimbursements; definitions. (a) For purposes of this section: "Covered services" means dental care services for which reimbursement is available/ under an enrollee's plan contract, or for which reimbursement would be available but for the application of contractual limitations such as deductibles, copayments, coinsurance, waiting periods, annual or lifetime maximum, frequency limitations, alternative benefit payments, or any other limitation. "Contractual discount" means a percentage reduction from the provider's usual and customary rate for covered dental services and materials required under a participating provider agreement. "Dental plan" includes any policy of insurance which is issued by a health care service contractor which provides for coverage of dental selrvices not in connection with a medical plan. s "Materials" includes, but is not limited to, iany material or device utilized within the scope of practice by a licensed dentist. (b) No contract of any health care service contractor that covers any dental services, and no contract or participating provider agreement with a dentist may require, directly or indirectly, that a dentist who is a participating provider, provide services to an enrolled participant at a fee set by, or a fee subject to the approval of, the health care services contractor unless the dental services are covered services. (c) A health caVre service contractor or other person providing third-party administrator services shall not make available any providers in its dental network to a plan that sets dental fees for any services except covered services. (d) A dentist may not charge more for services and materials that are noncovered services under a dental benefits policy than his or her usual and customary fee for those services and materials. (e) Reimbursement paid by a dental plan for covered services and materials shall be reasonable and may not provide nominal reimbursement in order to claim that services and materials are covered services. (f) This section applies to dental plans, contracts, and participating provider agreements which take effect or are renewed on or after July 1, 2019.
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