31.12.04.04

.04 Dental Benefit Contract.

Each dental benefit contract shall contain the following provisions:

A. The effective date of contract provision;

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

C. A grace period provision, pursuant to Regulation .05 of this chapter;

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

E. A provision describing the benefits available under the contract;

F. A provision describing the copayments for which the enrollee is responsible;

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

H. If a dental plan organization generally provides benefits only within a stated service area, a provision providing for emergency dental services outside the service area, with the term "emergency" including care to alleviate acute pain;

I. For closed panel dental benefit contracts:

(1) A provision indicating that if a plan dentist refers the enrollee to a specialist who is not a plan dentist for dental services which are covered under the dental benefit contract, the dental plan organization shall be responsible for payment of the specialist’s charges to the extent the charges exceed the copayment specified in the dental benefit contract; and

(2) A provision which reads substantially as follows: “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 the enrollee’s 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 which are listed in the patient charge schedule as No Charge, 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. The dental plan organization agrees to be subject to the jurisdiction of the Maryland Insurance Commissioner in any determination of the impossibility of providing services by plan dentists.”;

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

K. A provision setting out a grievance procedure provision that complies with the requirements of Insurance Article, Title 15, Subtitle 10D, and as applicable, Subtitle 10A, Annotated Code of Maryland; and

L. A provision setting out an extension of benefits in accordance with Insurance Article, §15-833, Annotated Code of Maryland.