Section 1374.19 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1374.19
. (a) This section shall only apply to a health care
service plan covering dental services or a specialized health care
service plan contract covering dental service pursuant to this
chapter.
(b) For purposes of this section, the following terms have the
following meanings:
(1) "Coordination of benefits" means the method by which a health
care service plan covering dental services or a specialized health
care service plan contract, covering dental services, and one or more
other health care service plans, specialized health care service
plans, or disability insurers, covering dental services, pay their
respective reimbursements for dental benefits when an enrollee is
covered by multiple health care service plans or specialized health
care services plan contracts, or a combination thereof, or a
combination of health care service plans or specialized health care
service plan contracts and disability insurers.
(2) "Primary dental benefit plan" means a health care service plan
or specialized health care service plan contract regulated pursuant
to this chapter or a dental insurance policy issued by a disability
insurer regulated pursuant to Part 2 (commencing with Section 10110)
of Division 2 of the Insurance Code that provides an enrollee or
insured with primary dental coverage.
(3) "Secondary dental benefit plan" means a health care service
plan or specialized health care service plan contract regulated
pursuant to this chapter or a dental insurance policy issued by a
disability insurer regulated pursuant to Part 2 (commencing with
Section 10110) of Division 2 of the Insurance Code that provides an
enrollee or insured with secondary dental coverage.
(c) A health care service plan covering dental services or a
specialized health care service plan issuing a specialized health
care service plan contract covering dental services shall declare its
coordination of benefits policy prominently in its evidence of
coverage or contract with both enrollee and subscriber.
(d) When a primary dental benefit plan is coordinating its
benefits with one or more secondary dental benefits plans, it shall
pay the maximum amount required by its contract with the enrollee or
subscriber.
(e) A health care service plan covering dental services or a
specialized health care service plan contract covering dental
services, when acting as a secondary dental benefit plan, shall pay
the lesser of either the amount that it would have paid in the
absence of any other dental benefit coverage, or the enrollee's total
out-of-pocket cost payable under the primary dental benefit plan for
benefits covered under the secondary plan.
(f) Nothing in this section is intended to conflict with or modify
the way in which a health care service plan covering dental services
or a specialized health care service plan covering dental services
determines which dental benefit plan is primary and which is
secondary in coordinating benefits with another plan or insurer
pursuant to existing state law or regulation.