# Title 26.1 — Insurance

## Chapter 26.1-36.9 — Dental Benefit Plans

### § 26.1-36.9-01. Definitions.

As used in this chapter:
1. "Dental benefit plan" means a benefits plan that pays or provides dental expense
benefits for covered dental services and is delivered through a dental insurer.
2. "Dental insurer" means a dental insurance company, dental service corporation, or
dental plan organization authorized to provide dental benefits.
3. "Dental provider" means a licensed provider of dental services in this state.
4. "Dental services" means services for the diagnosis, prevention, treatment, or cure of a
dental condition, illness, injury, or disease.
5. "Prior authorization" means confirmation by the covered individual's dental benefit plan
that the services sought to be provided by the dental provider meet the criteria for
coverage under the covered individual's dental benefit plan as defined by the covered
individual's dental benefit plan.
### § 26.1-36.9-02. Dental benefit plans - Prior authorization.

A dental benefit plan may not deny a claim subsequently submitted by a dental provider for
procedures specifically included in a prior authorization, unless at least one of the following
circumstances applies for each procedure denied:
1. Benefit limitations, such as annual maximums and frequency limitations not applicable
at the time of the prior authorization, are reached due to utilization after issuance of
the prior authorization.
2. The documentation for the claim provided by the dental provider submitting the claim
clearly fails to support the claim as originally authorized.
3. If, after the issuance of the prior authorization, new procedures are provided to the
patient or a change in the condition of the patient occurs such that the prior authorized
procedure would no longer be considered medically necessary, based on the
prevailing standard of care.
4. If, after the issuance of the prior authorization, new procedures are provided to the
patient or a change in the patient's condition occurs such that the prior authorized
procedure would at that time require disapproval pursuant to the terms and conditions
for coverage under the patient's plan in effect at the time the prior authorization was
used.
5. The denial of the payment was due to one of the following:
a. Another payor is responsible for payment.
b. The dental provider already has been paid for the procedures identified on the
claim.
c. The claim was submitted fraudulently.
d. The individual receiving the procedure was not eligible to receive the procedure
on the date of service.
### § 26.1-36.9-03. Dental insurer rates - Approval.

(Effective after June 30, 2027)
1. The commissioner may deem a proposed plan rate of a dental insurer to be excessive
and disapprove the proposed plan rate if the dental insurer files a rate change and the:
a. Administrative expense component, not including taxes and assessments,
increases from the previous year's rate filing by more than four percent;
b. Reported contribution to surplus exceeds two percent of total revenue; or
c. Dental loss ratio for the plan is less than seventy-five percent.
2. a. If the annual dental loss ratio for a dental benefit plan is less than seventy-five
percent, the dental insurer offering the plan shall refund the excess premium to
covered individuals and groups. As used in this section, "dental loss ratio" means
the ratio used to determine the minimum percentage of all premium funds
collected by a dental insurer each year which must be spent on actual patient

care rather than overhead costs. This minimum required percentage that dental
benefit plans must meet for the portion of patient premiums must be dedicated to
patient care rather than administrative and overhead costs or the difference must
be refunded as provided in this section.
b. A dental insurer shall provide notice to all individuals and groups that were
covered under the plan during the applicable twelve-month period that such
individuals and groups are entitled to a refund on the premium, or if the individual
or group remains covered by the dental insurer, that the individual or group is
eligible for a credit on the premium for the following twelve-month period.
c. The total of all refunds issued under this subsection must equal the amount of the
dental insurer's earned premium which exceeds the amount necessary to achieve
a dental loss ratio of seventy-five percent, calculated using data reported by the
dental insurer.
d. The dental loss ratio is calculated by dividing the numerator by the denominator
as follows:
(1) The numerator is the amount spent on care, which must include:
(a) The amount expended for clinical dental services that are services
within the code on dental procedures and nomenclature, provided to
enrollees which includes payments under capitation contracts with
dental providers, whose services are covered by the contract for
dental clinical services or supplies covered by the contract;
(b) Unpaid claim reserves; and
(c) Any claim payment recovered by insurers from providers or enrollees
using utilization management efforts, which are deducted from
incurred claims amounts.
(2) Any overpayment received from a provider may not be reported as a paid
claim. Overpayment recoveries received from a provider must be deducted
from incurred claims amounts.
(3) The calculation of the numerator does not include:
(a) All administrative costs, including infrastructure, personnel costs, or
broker payments;
(b) Amounts paid to third-party vendors for secondary network savings;
(c) Amounts paid to third-party vendors for network development,
administrative fees, claims processing, and utilization management; or
(d) Amounts paid to providers for professional or administrative services
that do not represent compensation or reimbursement for covered
services provided to an enrollee, including dental record copying
costs, attorney fees, subrogation vendor fees, and compensation to
paraprofessionals, janitors, quality assurance analysts, administrative
supervisors, secretaries to dental personnel, and dental record clerks.
(4) (a) The denominator is calculated using insurer revenue.
(b) The earned premium is all moneys paid by a policyholder or
subscriber as a condition of receiving coverage from the issuer,
including any fees or other contributions associated with the dental
benefit plan.
(c) The denominator is the total amount of the earned premium revenues,
excluding federal and state taxes and licensing and regulatory fees
paid after accounting for any payments pursuant to federal law.
3. The commissioner may:
a. Authorize a waiver or adjustment of the refund requirements in this section only if
it is determined by the commissioner that issuing refunds would result in financial
impairment for the dental insurer.
b. Adopt rules to implement and administer this section.
4. This section does not apply to a dental insurer with one thousand enrollees or less
cumulative of all plans based on a three-year average.

### § 26.1-36.9-04. Dental loss ratio transparency - Annual report to the commissioner.

1. A dental insurer that issues, sells, renews, or offers a specialized dental health care
service plan contract shall file a dental loss ratio report with the commissioner by April
thirtieth of each year, in a manner prescribed by the commissioner.
2. The dental loss ratio report must include dental loss ratio information for the last
calendar year for a dental benefit plan provided by a dental insurer and be organized
by market and product type.
3. The commissioner may request the dental insurer provide data verification of any
information provided by the dental insurer in the dental loss ratio report. The dental
insurer shall provide data verification to the commissioner within thirty days of the
request.
4. The commissioner shall make the information provided in the dental loss ratio annual
reports filed under this section available on the department's website, including the
aggregate dental loss ratio, in a manner that allows the public to compare dental loss
ratios among dental insurers by market type.
5. For purposes of this section, "dental loss ratio" has the same meaning as in section
26.1-36.9-03.
