Washington, DC—Congressman Earl “Buddy” Carter (R-GA) recently introduced a new bill titled “Dental and Optometric Care Access Act (DOC Access Act)” that would address conflicts between dentists and eyecare providers and insurance providers.
There are a number of similar bills at the state level that address doctor grievances, such as the limiting of laboratory choice, forcing discounts on noncovered services, and forcing doctors to participate in a vision plan as a condition for participating in a medical plan. The DOC Access Act would remedy some of these conflicts.
“This bill is a counterattack to policies that have been threatening optometric practices across the country as well as the patients they serve,” says William T. Reynolds, OD, American Optometric Association (AOA) trustee. “These are all unfair provisions that the insurance industry has put in. They’ve already been attacked on the state level, and now the AOA is attacking them on a federal level.”
Details of the bill
HR 3323 aims to improve coverage under dental and vision plans by outlining the following provisions:
• In general: “The plan or coverage shall provide, with respect to a doctor of optometry, doctor of dental surgery, or doctor of dental medicine that has an agreement to participate in the plan or coverage and that furnishes items or services that are not covered by the plan or coverage to a person enrolled under such plan or coverage, that the doctor may charge the enrollee for such items or services any amount determined by the doctor that is equal to, or less than, the usual and customary amount that the doctor charges individuals who are not so enrolled for such items or services.”
• Regarding covered items and services: “An item or service shall be considered, with respect to a plan or coverage, to be covered by the plan or coverage only if the negotiated rate agreed to by such plan or coverage and the doctor for such item or service, without regard to any cost sharing obligation of the enrollee, is an amount that is reasonable and is not nominal or de minimis.”
• Regarding changes to the plan: “The terms of an agreement between such a plan or coverage and such a doctor (including, in the case of a plan or coverage that provides for a provider network, the negotiated rate for providers that participate in the network of such plan or coverage), may be changed only pursuant to a subsequent agreement signed by the doctor that documents the acknowledgment and acceptance of the doctor (as applicable) to such changes.”
• Regarding the duration of limited-scope plans: “In the case of an agreement between such a doctor and such a plan or coverage that offers limited scope dental or vision benefits, the agreement may not be for a period that is greater than two years.”
• Regarding ancillary services and procedures: “Such plan or coverage may not deny such a doctor participation in the plan or coverage or remove such a doctor from participation in the plan or coverage for the sole reason of the failure of the doctor to accept the terms and conditions under such agreement for any ancillary service or procedure.”
• Regarding the conditions to join a provider network: “The plan or coverage may not require that such a doctor must participate with, or be credentialed by, any specific plan or coverage offering limited scope dental or vision benefits as a condition to participate in the provider network of such plan or coverage.”
• Regarding interference with existing relationships and requirements: “Unless otherwise required by law or regulation, such plan or coverage may not directly communicate with an individual enrolled in such plan or coverage in a manner that interferes with or contravenes any State or Federal requirement, or doctor-patient relationship in existence at the time of such communication.”
• Regarding laboratory choice: “The plan or coverage may not, directly or indirectly, restrict or limit, such a doctor’s choice of laboratories or choice of source and suppliers of services or materials provided by the doctor to an individual who is enrolled under the plan or coverage.”