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House Bill No. 5467

Public Act No. 04-125

AN ACT REQUIRING DISCLOSURE OF REIMBURSEMENT UNDER DENTAL PLANS AND REVISING THE MANAGED CARE ACT TO REFERENCE PROFESSIONAL COUNSELORS.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. (NEW) (Effective October 1, 2004) For any policy delivered, issued for delivery, renewed, amended or continued in this state on or after October 1, 2004, that provides coverage for inpatient or outpatient dental services only, the person who issues the policy shall provide the insured or a licensed dentist acting on behalf of the insured, upon request, an estimate of reimbursement under the policy with respect to specific dental procedure codes ordered or recommended for the insured by a licensed dentist, except that the actual reimbursement may be adjusted based on factors such as the insured's eligibility, plan design, utilization of benefits and the actual claim submitted.

Sec. 2. Section 38a-478 of the general statutes, as amended by section 10 of public act 03-169, is repealed and the following is substituted in lieu thereof (Effective October 1, 2004):

As used in sections 38a-478 to 38a-478o, inclusive, as amended, and subsection (a) of section 38a-478s:

(1) "Commissioner" means the Insurance Commissioner.

(2) "Managed care organization" means an insurer, health care center, hospital or medical service corporation or other organization delivering, issuing for delivery, renewing or amending any individual or group health managed care plan in this state.

(3) "Managed care plan" means a product offered by a managed care organization that provides for the financing or delivery of health care services to persons enrolled in the plan through: (A) Arrangements with selected providers to furnish health care services; (B) explicit standards for the selection of participating providers; (C) financial incentives for enrollees to use the participating providers and procedures provided for by the plan; or (D) arrangements that share risks with providers, provided the organization offering a plan described under subparagraph (A), (B), (C) or (D) of this subdivision is licensed by the Insurance Department pursuant to chapter 698, 698a or 700 and that the plan includes utilization review pursuant to sections 38a-226 to 38a-226d, inclusive.

(4) "Provider" means a person licensed to provide health care services under chapters 370 to 373, inclusive, 375 to [383b] 383c, inclusive, 384a to 384c, inclusive, or chapter 400j.

(5) "Enrollee" means a person who has contracted for or who participates in a managed care plan for himself or his eligible dependents.

(6) "Preferred provider network" means a preferred provider network, as defined in section 38a-479aa, as amended.

(7) "Utilization review" means utilization review, as defined in section 38a-226.

(8) "Utilization review company" means a utilization review company, as defined in section 38a-226.

Approved May 21, 2004