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 orpremiums;
3. A grace period provision that complies with § 38.2-6107;
4. For group dental benefit contracts, the eligibility requirements andeffective date of coverage for subscribers of the group and their dependents;
5. A provision describing the benefits available under the dental benefitcontract;
6. A provision describing the copayments and deductibles for which theenrollee 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 statedservice area, a provision providing for emergency dental services outside theservice area, with the term "emergency" including care to alleviate acutepain;
9. A provision indicating that if a plan dentist refers the enrollee to aspecialist who is not a plan dentist for dental services that are coveredunder the dental benefit contract, the dental plan organization shall beresponsible for payment of the specialist's charges to the extent the chargesexceed the copayment specified in the dental benefit contract;
10. A provision that reads substantially as follows, if the contract requiresuse of a plan dentist:
"If during the term of this contract none of the plan dentists can rendernecessary care and treatment to the enrollee due to circumstances notreasonably within the control of the dental plan organization, such ascomplete or partial destruction of facilities, war, riot, civil insurrection,labor disputes, or the disability of a significant number of the plandentists, then the enrollee may seek treatment from an independent licenseddentist of his own choosing. The dental plan organization will pay theenrollee for the expenses incurred for the dental services with the followinglimitations: The dental plan organization will pay the enrollee for servicesthat are listed in the patient charge schedule as "No Charge," to theextent that such fees are reasonable and customary for dentists in the samegeographic area; the dental plan organization will also pay the enrollee forthose services listed in the contract for which there is a copayment, to theextent that the reasonable and customary fees for such services exceed thecopayment for such services as set forth in the contract. The enrollee may berequired to give written proof of loss.";
11. A provision setting out the terms under which coverage will terminate; and
12. A provision setting out a grievance procedure that specifies the timeperiod in which the dental plan organization shall initially respond to anenrollee's grievance, with the time period not exceeding 20 days from thedate the grievance is filed with the dental plan organization.
B. Each dental benefit contract shall also have provisions related toextension of benefits that specify:
1. If an enrollee's coverage terminates, an extension of benefits shall beprovided for any treatment in progress at the time of termination, providedthe treatment requires two or more visits to the dentist's office on separatedays as certified by the treating dentist.
2. The extension of benefits shall be, at a minimum, for all types of dentalcare other than orthodontics, until the completion of the procedure.
3. For orthodontics, the extension of benefits will be at least 60 days ifthe orthodontist has agreed to or is receiving monthly payments when coverageterminates, or if the orthodontist has agreed to accept or is receivingpayments on a quarterly basis, to the end of the quarter in progress or 60days, whichever is longer.
4. An extension of benefits is not required if termination is due solely tothe failure of the enrollee to pay the subscription fee or premium when theenrollee is otherwise eligible to continue coverage under the dental benefitcontract.
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 orpremiums;
3. A grace period provision that complies with § 38.2-6107;
4. For group dental benefit contracts, the eligibility requirements andeffective date of coverage for subscribers of the group and their dependents;
5. A provision describing the benefits available under the dental benefitcontract;
6. A provision describing the copayments and deductibles for which theenrollee 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 statedservice area, a provision providing for emergency dental services outside theservice area, with the term "emergency" including care to alleviate acutepain;
9. A provision indicating that if a plan dentist refers the enrollee to aspecialist who is not a plan dentist for dental services that are coveredunder the dental benefit contract, the dental plan organization shall beresponsible for payment of the specialist's charges to the extent the chargesexceed the copayment specified in the dental benefit contract;
10. A provision that reads substantially as follows, if the contract requiresuse of a plan dentist:
"If during the term of this contract none of the plan dentists can rendernecessary care and treatment to the enrollee due to circumstances notreasonably within the control of the dental plan organization, such ascomplete or partial destruction of facilities, war, riot, civil insurrection,labor disputes, or the disability of a significant number of the plandentists, then the enrollee may seek treatment from an independent licenseddentist of his own choosing. The dental plan organization will pay theenrollee for the expenses incurred for the dental services with the followinglimitations: The dental plan organization will pay the enrollee for servicesthat are listed in the patient charge schedule as "No Charge," to theextent that such fees are reasonable and customary for dentists in the samegeographic area; the dental plan organization will also pay the enrollee forthose services listed in the contract for which there is a copayment, to theextent that the reasonable and customary fees for such services exceed thecopayment for such services as set forth in the contract. The enrollee may berequired to give written proof of loss.";
11. A provision setting out the terms under which coverage will terminate; and
12. A provision setting out a grievance procedure that specifies the timeperiod in which the dental plan organization shall initially respond to anenrollee's grievance, with the time period not exceeding 20 days from thedate the grievance is filed with the dental plan organization.
B. Each dental benefit contract shall also have provisions related toextension of benefits that specify:
1. If an enrollee's coverage terminates, an extension of benefits shall beprovided for any treatment in progress at the time of termination, providedthe treatment requires two or more visits to the dentist's office on separatedays as certified by the treating dentist.
2. The extension of benefits shall be, at a minimum, for all types of dentalcare other than orthodontics, until the completion of the procedure.
3. For orthodontics, the extension of benefits will be at least 60 days ifthe orthodontist has agreed to or is receiving monthly payments when coverageterminates, or if the orthodontist has agreed to accept or is receivingpayments on a quarterly basis, to the end of the quarter in progress or 60days, whichever is longer.
4. An extension of benefits is not required if termination is due solely tothe failure of the enrollee to pay the subscription fee or premium when theenrollee is otherwise eligible to continue coverage under the dental benefitcontract.
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 orpremiums;
3. A grace period provision that complies with § 38.2-6107;
4. For group dental benefit contracts, the eligibility requirements andeffective date of coverage for subscribers of the group and their dependents;
5. A provision describing the benefits available under the dental benefitcontract;
6. A provision describing the copayments and deductibles for which theenrollee 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 statedservice area, a provision providing for emergency dental services outside theservice area, with the term "emergency" including care to alleviate acutepain;
9. A provision indicating that if a plan dentist refers the enrollee to aspecialist who is not a plan dentist for dental services that are coveredunder the dental benefit contract, the dental plan organization shall beresponsible for payment of the specialist's charges to the extent the chargesexceed the copayment specified in the dental benefit contract;
10. A provision that reads substantially as follows, if the contract requiresuse of a plan dentist:
"If during the term of this contract none of the plan dentists can rendernecessary care and treatment to the enrollee due to circumstances notreasonably within the control of the dental plan organization, such ascomplete or partial destruction of facilities, war, riot, civil insurrection,labor disputes, or the disability of a significant number of the plandentists, then the enrollee may seek treatment from an independent licenseddentist of his own choosing. The dental plan organization will pay theenrollee for the expenses incurred for the dental services with the followinglimitations: The dental plan organization will pay the enrollee for servicesthat are listed in the patient charge schedule as "No Charge," to theextent that such fees are reasonable and customary for dentists in the samegeographic area; the dental plan organization will also pay the enrollee forthose services listed in the contract for which there is a copayment, to theextent that the reasonable and customary fees for such services exceed thecopayment for such services as set forth in the contract. The enrollee may berequired to give written proof of loss.";
11. A provision setting out the terms under which coverage will terminate; and
12. A provision setting out a grievance procedure that specifies the timeperiod in which the dental plan organization shall initially respond to anenrollee's grievance, with the time period not exceeding 20 days from thedate the grievance is filed with the dental plan organization.
B. Each dental benefit contract shall also have provisions related toextension of benefits that specify:
1. If an enrollee's coverage terminates, an extension of benefits shall beprovided for any treatment in progress at the time of termination, providedthe treatment requires two or more visits to the dentist's office on separatedays as certified by the treating dentist.
2. The extension of benefits shall be, at a minimum, for all types of dentalcare other than orthodontics, until the completion of the procedure.
3. For orthodontics, the extension of benefits will be at least 60 days ifthe orthodontist has agreed to or is receiving monthly payments when coverageterminates, or if the orthodontist has agreed to accept or is receivingpayments on a quarterly basis, to the end of the quarter in progress or 60days, whichever is longer.
4. An extension of benefits is not required if termination is due solely tothe failure of the enrollee to pay the subscription fee or premium when theenrollee is otherwise eligible to continue coverage under the dental benefitcontract.
