Virginia Code 38.2-6106: Optional provisions
Dental benefit contracts may contain the following provisions:
Terms Used In Virginia Code 38.2-6106
- Contract: A legal written agreement that becomes binding when signed.
- Contract holder: means (i) with respect to group contracts, the organization or entity to which the dental benefit contract is issued, and (ii) with respect to individual contracts, the individual who enters into a dental benefit contract covering the individual or the individual and dependents of the individual. See Virginia Code 38.2-6101
- Dental benefit contract: means a contract that provides benefits for dental services entered into between the dental plan organization and a contract holder. See Virginia Code 38.2-6101
- Dental plan: means a contractual arrangement for dental services provided or arranged for, that pays benefits or is administered on an individual or group basis. See Virginia Code 38.2-6101
- Dental plan organization: means a company that provides directly or arranges for a dental plan. See Virginia Code 38.2-6101
- Dependent: means an individual who is the spouse or child of a subscriber. See Virginia Code 38.2-6101
- Dependent: A person dependent for support upon another.
- Enrollee: means an individual or a dependent of an individual who is enrolled in a dental plan. See Virginia Code 38.2-6101
- Plan dentist: means any dentist, licensed by the Virginia Board of Dentistry, who has contracted with the dental plan organization or with an entity acting on behalf of the dental plan organization to provide dental services to the enrollees. See Virginia Code 38.2-6101
- rates: means any rate of premium, policy fee, membership fee or any other charge made by an insurer for or in connection with a contract or policy of insurance. See Virginia Code 38.2-100
1. A provision including the dental plan organization’s intention to charge a specified missed appointment fee. The fee shall be reasonable in relation to the nature of the procedure for which the missed appointment had been made. Neither the plan dentist nor the dental plan organization may charge a missed appointment fee unless this provision appears in the dental benefit contract. For purposes of this section, the term “missed appointment” means an appointment for which advance cancellation of at least 24 hours was not provided.
2. A provision including the dental plan organization’s ability to increase premiums or subscription fees, with this provision indicating that these fees may not be increased unless:
a. The contract holder has been given written notice at least 60 days before the effective date of the increase; and
b. In the case of:
(1) An individual contract, present rates under the contract have not been changed for at least 12 months, or
(2) A group contract, present rates under the contract have been in effect for at least 12 months.
3. A provision including the dental plan organization’s intention to impose a financial penalty on an enrollee for voluntarily withdrawing from the dental plan during the first year of coverage, which penalty may not:
a. Be charged if the enrollee withdraws from the dental plan after being covered for at least 12 months; or
b. Exceed the usual, customary, and reasonable charge for services received reduced by the sum of the subscription fees paid by or for the enrollee and any copayments paid by or for the enrollee.
4. A provision including the dental plan organization’s ability to increase the patient charge schedule, with the provision indicating that the increase may not be effective unless the:
a. Present schedule under the contract has been in effect for at least 12 months; and
b. Contract holder has been given written notice of the increase at least 60 days before the effective date of the increase.
5. A provision including the dental plan organization’s rights if an enrollee refuses to follow a particular course of treatment. The dental plan organization may not terminate the membership of an enrollee for refusal to follow a recommended course of treatment for a particular condition. The provision may indicate that the dental plan organization may refuse to provide any further benefits for the particular condition if the enrollee refuses to accept a recommended course of treatment.
6. A provision including the dental plan organization’s rights if an enrollee fraudulently uses his membership card or knowingly permits his membership card to be used by others. The dental plan organization may terminate an enrollee’s coverage if the enrollee fraudulently uses his membership card or knowingly permits his membership card to be used by others. The dental plan organization may not terminate coverage for an entire family because a dependent fraudulently uses the membership card. In this instance, only the dependent‘s coverage may terminate.
7. A provision specifying that the dental plan organization may terminate an enrollee’s coverage if the enrollee is unable to maintain a satisfactory dentist-patient relationship with a plan dentist, provided, however:
a. Before terminating the enrollee’s coverage, the dental plan organization shall permit the enrollee to change primary dentists at least once;
b. The enrollee shall be given written notice of the termination at least 30 days before the termination of the enrollee’s membership.
8. If the contract provides coverage for dependent children, the contract shall also contain the following provision:
“Notwithstanding any limiting age stated in the contract, any unmarried child covered under the contract as a dependent of an enrollee who is chiefly dependent for support upon the enrollee, and who, at the time of reaching the limiting age, is incapable of self-support because of mental or physical incapacity that commenced prior to the child’s attaining the limiting age, shall continue to be covered under the contract while remaining so dependent, unmarried, and mentally or physically incapacitated, until the coverage on the enrollee upon whom the child is dependent terminates.”
2004, c. 668.