Dental and Optometric Care Access Act or the DOC Access Act
This bill amends the Public Health Service Act to prohibit group health plans and individual health insurance coverage from setting rates for items and services provided by a doctor of optometry, of dental surgery, or of dental medicine for which the plan or insurer does not pay a substantial amount.
An agreement between a plan or insurer and such a doctor: (1) may only be changed with the doctor's acknowledgement and acceptance, and (2) may not last longer than two years if the agreement is for limited scope dental or vision benefits.
Such a doctor must be allowed to participate in a: (1) plan or coverage without accepting terms for ancillary services or procedures, and (2) provider network without participating in a specific limited scope dental or vision benefit plan.
Plans and insurers may not: (1) directly communicate with an enrolled individual in a manner that interferes with an existing doctor-patient relationship or a state or federal requirement, or (2) restrict such a doctor's choice of laboratories or suppliers.
The bill establishes a private right of action for a person adversely affected by a violation of this Act.
[Congressional Bills 114th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3323 Introduced in House (IH)]
114th CONGRESS
1st Session
H. R. 3323
To amend title XXVII of the Public Health Service Act to improve health
care coverage under vision and dental plans, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 29, 2015
Mr. Carter of Georgia introduced the following bill; which was referred
to the Committee on Energy and Commerce
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act to improve health
care coverage under vision and dental plans, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Dental and Optometric Care Access
Act'' or the ``DOC Access Act''.
SEC. 2. IMPROVING HEALTH CARE COVERAGE UNDER VISION AND DENTAL PLANS.
(a) In General.--Title XXVII of the Public Health Service Act is
amended by inserting after section 2719A (42 U.S.C. 300gg-19a) the
following new section:
``SEC. 2719B. IMPROVING COVERAGE UNDER VISION AND DENTAL PLANS.
``(a) In General.--Under a group health plan or individual or
health insurance coverage (including such a plan or coverage offering
limited scope dental or vision benefits), the following shall apply:
``(1) Payment amounts from covered persons.--
``(A) 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.
``(B) Items and services considered covered by a
plan.--For purposes of subparagraph (A), 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.
``(2) Changes to plans.--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.
``(3) Duration of limited scope vision and dental 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.
``(4) Terms and conditions for 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.
``(5) Condition 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.
``(6) No 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.
``(7) No restriction on choice of laboratories.--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.
``(b) Private Right of Action.--In addition to any other remedies
under State or Federal law, a person adversely affected by a violation
of this subsection may bring action for injunctive relief against a
plan described in subsection (a) and, upon prevailing, in addition to
such injunctive relief, shall recover monetary damages of no more than
$1,000 for each day found to be in violation plus attorney's fees and
costs. The district courts of the United States shall have exclusive
jurisdiction of civil actions brought under this subsection.
``(c) Relationship to Exception for Limited, Excepted Benefits.--
Section 2722(c)(1) shall not apply with respect to the requirements of
this section.
``(d) Definitions.--In this section:
``(1) The terms `doctor of dental surgery' and `doctor of
dental medicine' mean a doctor of dental surgery or of dental
medicine, as applicable, who is legally authorized to practice
dentistry by the State in which the doctor performs such
function and who is acting within the scope of the license of
the doctor when performing such functions.
``(2) The term `doctor of optometry' means a doctor of
optometry who is legally authorized to practice optometry by
the State in which the doctor so practices.''.
(b) Conforming Amendment.--Section 2722(c)(1) of the Public Health
Service Act (42 U.S.C. 300gg-21(c)(1)) is amended by striking ``The
requirements'' and inserting ``Subject to section 2719B, the
requirements''.
<all>
Introduced in House
Introduced in House
Referred to the House Committee on Energy and Commerce.
Referred to the Subcommittee on Health.
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