                                 CODE OF VIRGINIA

REQUIRED DENTAL BENEFIT CONTRACT PROVISIONS (§ 38.2-6105)

A. Each dental benefit contract shall contain the following provisions:

   1. An effective date of the contract;

   2. A provision describing the payment of required subscription fees or
   premiums;

   3. A grace period provision that complies with &#xA7; 38.2-6107;

   4. For group dental benefit contracts, the eligibility requirements and
   effective date of coverage for subscribers of the group and their dependents;

   5. A provision describing the benefits available under the dental benefit
   contract;

   6. A provision describing the copayments and deductibles for which the
   enrollee is responsible or the fixed indemnity benefits, if any;

   7. A provision describing the service area, if applicable;

   8. If a dental plan organization provides benefits only within a stated
   service area, a provision providing for emergency dental services outside the
   service area, with the term &#8220;emergency&#8221; including care to
   alleviate acute pain;

   9. A provision indicating that if a plan dentist refers the enrollee to a
   specialist who is not a plan dentist for dental services that are covered
   under the dental benefit contract, the dental plan organization shall be
   responsible for payment of the specialist&#8217;s charges to the extent the
   charges exceed the copayment specified in the dental benefit contract;

   10. A provision that reads substantially as follows, if the contract requires
   use of a plan dentist:
   				&#8220;If during the term of this contract none of the plan dentists can
   render necessary care and treatment to the enrollee due to circumstances not
   reasonably within the control of the dental plan organization, such as
   complete or partial destruction of facilities, war, riot, civil insurrection,
   labor disputes, or the disability of a significant number of the plan
   dentists, then the enrollee may seek treatment from an independent licensed
   dentist of his own choosing. The dental plan organization will pay the
   enrollee for the expenses incurred for the dental services with the following
   limitations: The dental plan organization will pay the enrollee for services
   that are listed in the patient charge schedule as &#8220;No Charge,&#8221; to
   the extent that such fees are reasonable and customary for dentists in the
   same geographic area; the dental plan organization will also pay the enrollee
   for those services listed in the contract for which there is a copayment, to
   the extent that the reasonable and customary fees for such services exceed the
   copayment for such services as set forth in the contract. The enrollee may be
   required to give written proof of loss.&#8221;;

   11. A provision setting out the terms under which coverage will terminate; and

   12. A provision setting out a grievance procedure that specifies the time
   period in which the dental plan organization shall initially respond to an
   enrollee&#8217;s grievance, with the time period not exceeding 20 days from
   the date the grievance is filed with the dental plan organization.

B. Each dental benefit contract shall also have provisions related to extension
of benefits that specify:

   1. If an enrollee&#8217;s coverage terminates, an extension of benefits shall
   be provided for any treatment in progress at the time of termination, provided
   the treatment requires two or more visits to the dentist&#8217;s office on
   separate days as certified by the treating dentist.

   2. The extension of benefits shall be, at a minimum, for all types of dental
   care other than orthodontics, until the completion of the procedure.

   3. For orthodontics, the extension of benefits will be at least 60 days if the
   orthodontist has agreed to or is receiving monthly payments when coverage
   terminates, or if the orthodontist has agreed to accept or is receiving
   payments on a quarterly basis, to the end of the quarter in progress or 60
   days, whichever is longer.

   4. An extension of benefits is not required if termination is due solely to
   the failure of the enrollee to pay the subscription fee or premium when the
   enrollee is otherwise eligible to continue coverage under the dental benefit
   contract.

HISTORY: 2004, c. 668.