31.12.04.07

.07 Optional Provisions.

A. Dental benefit contracts may contain the provisions in §§B—D of this regulation, and if any of the provisions are included in a group dental benefit contract, the same provision shall be contained in the corresponding evidence of coverage.

B. General Provisions.

(1) A provision may be included specifying 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.

(2) A provision may be included specifying 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 45 days before the effective date of the increase; and

(b) In the case of:

(i) An individual contract, present rates have not been changed for at least 12 months,

(ii) A group contract, present rates under the contract have been in effect for at least 12 months.

(3) A provision may be included specifying 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 may be included specifying 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 has been in effect for at least 12 months; and

(b) Contract holder has been given written notice of the increase at least 30 days before the effective date of the increase.

(5) A provision may be included specifying 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 an appropriate 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 the recommended course of treatment.

(6) A provision may be included specifying 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.

C. Termination Provision. A provision may be included which specifies 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, with this provision:

(1) Indicating that before terminating the enrollee's coverage, the dental plan organization shall permit the enrollee to change primary dentists at least once;

(2) Specifying that the enrollee shall be given written notice of the termination at least 30 days before the termination of the enrollee's membership.

D. Dependent Children Provision. 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."