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<ns0:Id>20250AB__202998AMD</ns0:Id>
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<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2026-02-17</ns0:ActionDate>
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<ns0:Action>
<ns0:ActionText>AMENDED_ASSEMBLY</ns0:ActionText>
<ns0:ActionDate>2026-03-19</ns0:ActionDate>
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<ns0:SessionYear>2025</ns0:SessionYear>
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<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Sharp-Collins</ns0:AuthorText>
<ns0:Authors>
<ns0:Legislator>
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<ns0:House>ASSEMBLY</ns0:House>
<ns0:Name>Sharp-Collins</ns0:Name>
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<ns0:Title> An act to add Section 1374.190 to the Health and Safety Code, and to add Section 10120.45 to the Insurance Code, relating to healing arts. </ns0:Title>
<ns0:RelatingClause>healing arts</ns0:RelatingClause>
<ns0:GeneralSubject>
<ns0:Subject>Dental plan portal.</ns0:Subject>
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<html:p>Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act’s requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law sets forth requirements for a contract between a plan or insurer and a dentist and requires a plan or insurer to make specified disclosures to an enrollee or insured regarding noncovered dental services.</html:p>
<html:p>This bill would require a dental plan or dental insurer to establish a dental portal accessible to a treating dental provider to provide information regarding an enrollee’s contract or insured’s policy, including the
actual payment or reimbursement amounts for covered services. The bill would require the portal to provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format, provide specified information about a corresponding payment, accept attachments in an electronic format, and be made available at no cost to contracted and noncontracted dental providers, among other requirements. Because a willful violation of these provisions relative to health care service plans would be a crime, this bill would impose a state-mandated local program.</html:p>
<html:p>The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.</html:p>
<html:p>This bill would provide that no reimbursement is required by this act for a specified reason.</html:p>
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<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
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<ns0:Num>SECTION 1.</ns0:Num>
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Section 1374.190 is added to the
<ns0:DocName>Health and Safety Code</ns0:DocName>
,
<ns0:Positioning>immediately following Section 1374.19</ns0:Positioning>
, to read:
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<ns0:Num>1374.190.</ns0:Num>
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<html:p>
(a)
<html:span class="EnSpace"/>
A dental plan shall establish a dental portal that shall be accessible to a treating dental provider and shall provide information regarding an enrollee’s plan contract, including the actual payment or reimbursement amounts for covered services and an estimate of the enrollee’s out-of-pocket costs at the procedure code level. The information in the portal shall include all of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Effective and termination date of the plan contract.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Claim address.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Payer identification.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
A comprehensive list or procedure code-level
lookup tool of all American Dental Association current dental terminology (CDT) codes to provide an accurate estimate of coverage and enrollee cost, including all of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Covered services.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Applicability of in-network or out-of-network coinsurance percentage and amounts.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
If a deductible applies and to which services.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Applicability of coordination of benefits and if they are standard or nonduplicating.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Applicability of annual or lifetime maximums.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
Limitations on coverage due to the enrollee’s age.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
Limitations on coverage based
on frequency of prior treatment, services rendered per visit, quadrants treated per visit, tooth number, or time period.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
Alternative benefits, bundling, or downcoding that apply.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Applicability of a waiting period.
</html:p>
<html:p>
(J)
<html:span class="EnSpace"/>
Any prior authorization or documentation requirements or payment processing guidelines for any codes or services.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The next available service date or previous service dates based on any frequency limits, waiting periods, or benefits, such as coverage for medical conditions or benefit rollover.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
Previous 12 months of processed and pending claims applied to the enrollee’s annual maximum or deductible to help determine the remaining annual benefit available.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
Expiration of the estimate provided.
</html:p>
<html:p>
(8)
<html:span class="EnSpace"/>
Claim status.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
The dental portal shall provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format. It is the responsibility of the dental plan to ensure eligibility and benefits reporting is timely and accurate.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
The dental portal shall be able to accept attachments, including digital imaging and other documents or information supporting claims, in an electronic format with the initial electronic claim submission and any following submissions.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
The dental portal shall provide information about a corresponding payment that outlines all of the following individually per claim:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
The name of the enrollee.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The date of service.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The service code or description.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
The amount being paid.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The claim number.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
Denial information, including the reasons for denial and other identifying information found on an explanation of benefits form.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
A dental plan shall ensure that the dental portal is all of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Compliant with the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) and the regulations promulgated
thereunder.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Accessible 24 hours per day, seven days per week, except for reasonable maintenance periods.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Made available at no cost to both contracted and noncontracted dental providers treating enrollees.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
A dental plan shall provide clear instructions and technical support for the dental portal.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
Failure to comply with this section shall result in sanctions as determined by the department pursuant to Article 8 (commencing with Section 1390).
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
For purposes of this section:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
“Dental plan” means a health care service plan offering a contract covering dental services, or a specialized health care service plan
offering a contract covering dental services, pursuant to this chapter.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
“Dental portal” means an internet-based platform that provides resources and information to dental providers about enrollees’ eligibility, including estimates of coverage before treatment, the ability to track claims, and the ability to submit supporting documentation.
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<ns0:Num>SEC. 2.</ns0:Num>
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Section 10120.45 is added to the
<ns0:DocName>Insurance Code</ns0:DocName>
, to read:
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<ns0:LawSection id="id_054C1D2B-8ED6-41FF-B21D-4D28D6BBE3A5">
<ns0:Num>10120.45.</ns0:Num>
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<html:p>
(a)
<html:span class="EnSpace"/>
A dental insurer shall establish a dental portal that shall be accessible to a treating dental provider and shall provide information regarding an insured’s policy, including the actual payment or reimbursement amounts for covered services and an estimate of the insured’s out-of-pocket costs at the procedure code level. The information in the portal shall include all of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Effective and termination date of the policy.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Claim address.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Payer identification.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
A comprehensive list or procedure code-level lookup tool of all
American Dental Association current dental terminology (CDT) codes to provide an accurate estimate of coverage and insured cost, including all of the following:
</html:p>
<html:p>
(A)
<html:span class="EnSpace"/>
Covered services.
</html:p>
<html:p>
(B)
<html:span class="EnSpace"/>
Applicability of in-network or out-of-network coinsurance percentage and amounts.
</html:p>
<html:p>
(C)
<html:span class="EnSpace"/>
If a deductible applies and to which services.
</html:p>
<html:p>
(D)
<html:span class="EnSpace"/>
Applicability of coordination of benefits and if they are standard or nonduplicating.
</html:p>
<html:p>
(E)
<html:span class="EnSpace"/>
Applicability of annual or lifetime maximums.
</html:p>
<html:p>
(F)
<html:span class="EnSpace"/>
Limitations on coverage due to the insured’s age.
</html:p>
<html:p>
(G)
<html:span class="EnSpace"/>
Limitations on coverage based on frequency of
prior treatment, services rendered per visit, quadrants treated per visit, tooth number, or time period.
</html:p>
<html:p>
(H)
<html:span class="EnSpace"/>
Alternative benefits, bundling, or downcoding that apply.
</html:p>
<html:p>
(I)
<html:span class="EnSpace"/>
Applicability of a waiting period.
</html:p>
<html:p>
(J)
<html:span class="EnSpace"/>
Any prior authorization or documentation requirements or payment processing guidelines for any codes or services.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The next available service date or previous service dates based on any frequency limits, waiting periods, or benefits, such as coverage for medical conditions or benefit rollover.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
Previous 12 months of processed and pending claims applied to the insured’s annual maximum or deductible to help determine the remaining annual benefit available.
</html:p>
<html:p>
(7)
<html:span class="EnSpace"/>
Expiration of the estimate provided.
</html:p>
<html:p>
(8)
<html:span class="EnSpace"/>
Claim status.
</html:p>
<html:p>
(b)
<html:span class="EnSpace"/>
The dental portal shall provide accurate, real-time benefit eligibility and benefits information in a clear and understandable format. It is the responsibility of the dental insurer to ensure eligibility and benefits reporting is timely and accurate.
</html:p>
<html:p>
(c)
<html:span class="EnSpace"/>
The dental portal shall be able to accept attachments, including digital imaging and other documents or information supporting claims, in an electronic format with the initial electronic claim submission and any following submissions.
</html:p>
<html:p>
(d)
<html:span class="EnSpace"/>
The dental portal shall provide information about a corresponding payment that outlines all of the following individually per claim:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
The name of the insured.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
The date of service.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
The service code or description.
</html:p>
<html:p>
(4)
<html:span class="EnSpace"/>
The amount being paid.
</html:p>
<html:p>
(5)
<html:span class="EnSpace"/>
The claim number.
</html:p>
<html:p>
(6)
<html:span class="EnSpace"/>
Denial information, including the reasons for denial and other identifying information found on an explanation of benefits form.
</html:p>
<html:p>
(e)
<html:span class="EnSpace"/>
A dental insurer shall ensure that the dental portal is all of the following:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
Compliant with the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) and the regulations promulgated
thereunder.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
Accessible 24 hours per day, seven days per week, except for reasonable maintenance periods.
</html:p>
<html:p>
(3)
<html:span class="EnSpace"/>
Made available at no cost to both contracted and noncontracted dental providers treating insureds.
</html:p>
<html:p>
(f)
<html:span class="EnSpace"/>
A dental insurer shall provide clear instructions and technical support for the dental portal.
</html:p>
<html:p>
(g)
<html:span class="EnSpace"/>
Failure to comply with this section shall result in sanctions as determined by the department.
</html:p>
<html:p>
(h)
<html:span class="EnSpace"/>
For purposes of this section:
</html:p>
<html:p>
(1)
<html:span class="EnSpace"/>
“Dental insurer” means a health insurer offering a policy covering dental services, or a specialized health insurer offering a policy covering dental services, pursuant to this
chapter.
</html:p>
<html:p>
(2)
<html:span class="EnSpace"/>
“Dental portal” means an internet-based platform that provides resources and information to dental providers about insureds’ eligibility, including estimates of coverage before treatment, the ability to track claims, and the ability to submit supporting documentation.
</html:p>
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<ns0:Num>SEC. 3.</ns0:Num>
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<html:p>
No reimbursement is required by this act pursuant to Section 6 of Article XIII
<html:span class="ThinSpace"/>
B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII
<html:span class="ThinSpace"/>
B of the California Constitution.
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