SECTION 1. Section 27-18-63 of the General Laws in Chapter 27-18 entitled "Accident and Sickness Insurance Policies" is hereby amended to read as follows: 27-18-63. Dental insurance assignment of benefits.
(a) Every entity providing a policy of accident and sickness insurance as defined in this chapter shall allow, as a provision in a group or individual policy, contract, or health benefit plan for coverage of dental services, any person insured by such entity to direct, in writing, that benefits from a health benefit plan, policy, or contract, be paid directly to a dental care provider who has not contracted with the entity to provide dental services to persons covered by the entity but otherwise meets the credentialing criteria of the entity and has not previously been terminated by such entity as a participating provider. If written direction to pay is executed and written notice of the direction to pay is provided to such entity, the insuring entity shall pay the benefits directly to the dental care provider. Any efforts to modify the amount of benefits paid directly to the dental care provider under this section may include a reduction in benefits paid of no more than five percent (5%) less than the benefits paid to participating dentists. The entity paying the dentist, pursuant to a direction to pay duly executed by the subscriber, shall have the right to review the records of the dentist receiving such payment that relate exclusively to that particular subscriber/patient to determine that the service in question was rendered. Any entity as defined and licensed in this chapter shall allow, as a provision in any group or individual policy, contract, or health benefit plan for coverage of dental services, any person insured by the entity to direct, in writing, that their benefits, and the corresponding reimbursement to the dental care provider for covered services, from a health benefit plan, policy, or contract be paid directly to any dental care provider who has or has not contracted with the entity.
(b) Upon receipt of a duly executed written direction to pay and written notice thereof, the entity shall pay the benefits and compensation directly to the dental care provider. The amount of benefits paid under this section shall be no less than the highest reimbursement amount actually paid to any participating provider for the same covered dental service, as listed in the entity's benefit allowance tables or fee schedules, including any incentive-based or performance-tiered schedules.
(c) In cases where multiple tiers or schedules exist, the applicable benchmark shall be the highest reimbursement amount listed for that procedure code among all participating provider categories.
(d) The entity shall not use tiered reimbursement structures, geographic modifiers, or network classifications to reduce the benchmark amount for purposes of calculating payment under this section. The entity shall not create or designate new provider categories or reimbursement tiers for the purpose of reducing the benchmark amount under this section.
(e) The entity shall not reduce, modify, or condition the benefit amount based on the provider's non-participation. The entity may review the provider's records related exclusively to the subscriber/patient to verify that the service was rendered and to verify such treatment meets the entity's criteria for benefit payment.
(f) Provided, however, this section shall not apply to insurance coverage providing benefits for:
(1) Hospital confinement indemnity;
(2) Disability income;
(3) Accident only;
(4) Long-term care;
(5) Medicare supplement;
(6) Limited benefit health;
(7) Specified disease indemnity;
(8) Sickness or bodily injury or death by accident or both; and
(9) Other limited benefit policies.
SECTION 2. Section 27-19-54 of the General Laws in Chapter 27-19 entitled "Nonprofit Hospital Service Corporations" is hereby amended to read as follows: 27-19-54. Dental insurance assignment of benefits.
(a) Every entity providing a contract of insurance subject to this chapter shall allow, as a provision in a group or individual policy, contract, or health benefit plan for coverage of dental services, any person insured by the entity to direct, in writing, that benefits from a health benefit plan, policy, or contract be paid directly to a dental care provider who has not contracted with the entity to provide dental services to persons covered by the entity but otherwise meets the credentialing criteria of the entity and has not previously been terminated by the entity as a participating provider. If written direction to pay is executed and written notice of the direction to pay is provided to the entity, the insuring entity shall pay the benefits directly to the dental care provider. Any efforts to modify the amount of benefits paid directly to the dental care provider under this section may include a reduction in benefits paid of no more than five percent (5%) less than the benefits paid to participating dentists. The entity paying the dentist, pursuant to a direction to pay duly executed by the subscriber, shall have the right to review the records of the dentist receiving the payment that relate exclusively to that particular subscriber/patient to determine that the service in question was rendered. Any entity as defined and licensed in this chapter shall allow, as a provision in any group or individual policy, contract, or health benefit plan for coverage of dental services, any person insured by the entity to direct, in writing, that their benefits, and the corresponding reimbursement to the dental care provider for covered services, from a health benefit plan, policy, or contract be paid directly to any dental care provider who has or has not contracted with the entity.
(b) Upon receipt of a duly executed written direction to pay and written notice thereof, the entity shall pay the benefits and compensation directly to the dental care provider. The amount of benefits paid under this section shall be no less than the highest reimbursement amount actually paid to any participating provider for the same covered dental service, as listed in the entity's benefit allowance tables or fee schedules, including any incentive-based or performance-tiered schedules.
(c) In cases where multiple tiers or schedules exist, the applicable benchmark shall be the highest reimbursement amount listed for that procedure code among all participating provider categories.
(d) The entity shall not use tiered reimbursement structures, geographic modifiers, or network classifications to reduce the benchmark amount for purposes of calculating payment under this section. The entity shall not create or designate new provider categories or reimbursement tiers for the purpose of reducing the benchmark amount under this section.
(e) The entity shall not reduce, modify, or condition the benefit amount based on the provider's non-participation. The entity may review the provider's records related exclusively to the subscriber/patient to verify that the service was rendered and to verify such treatment meets the entity's criteria for benefit payment.
SECTION 3. Section 27-41-66 of the General Laws in Chapter 27-41 entitled "Health Maintenance Organizations" is hereby amended to read as follows: 27-41-66. Dental insurance assignment of benefits.
(a) Every entity licensed under this chapter shall allow, as a provision of any evidence of coverage of dental services, any person covered by the entity to direct, in writing, that benefits from a health benefit plan, policy, or contract, be paid directly to a dental care provider who has not contracted with the entity to provide dental services to persons covered by the entity but otherwise meets the credentialing criteria of the entity and has not previously been terminated by the entity as a participating provider. If written direction to pay is executed and written notice of the direction to pay is provided to the entity, the insuring entity shall pay the benefits directly to the dental care provider. Any efforts to modify the amount of benefits paid directly to the dental care provider under this section may include a reduction in benefits paid of no more than five percent (5%) less than the benefits paid to participating dentists. The entity paying the dentist, pursuant to a direction to pay duly executed by the subscriber, shall have the right to review the records of the dentist receiving such payment that relate exclusively to that particular subscriber/patient to determine that the service in question was rendered. Any entity as defined and licensed in this chapter shall allow, as a provision in any group or individual policy, contract, or health benefit plan for coverage of dental services, any person insured by the entity to direct, in writing, that their benefits, and the corresponding reimbursement to the dental care provider for covered services, from a health benefit plan, policy, or contract be paid directly to any dental care provider who has or has not contracted with the entity.
(b) Upon receipt of a duly executed written direction to pay and written notice thereof, the entity shall pay the benefits and compensation directly to the dental care provider. The amount of benefits paid under this section shall be no less than the highest reimbursement amount actually paid to any participating provider for the same covered dental service, as listed in the entity's benefit allowance tables or fee schedules, including any incentive-based or performance-tiered schedules.
(c) In cases where multiple tiers or schedules exist, the applicable benchmark shall be the highest reimbursement amount listed for that procedure code among all participating provider categories.
(d) The entity shall not use tiered reimbursement structures, geographic modifiers, or network classifications to reduce the benchmark amount for purposes of calculating payment under this section. The entity shall not create or designate new provider categories or reimbursement tiers for the purpose of reducing the benchmark amount under this section.
(e) The entity shall not reduce, modify, or condition the benefit amount based on the provider's non-participation. The entity may review the provider's records related exclusively to the subscriber/patient to verify that the service was rendered and to verify such treatment meets the entity's criteria for benefit payment.
SECTION 4. This act shall take effect on January 1, 2027.
