38.2-6106 - Optional provisions.
§ 38.2-6106. Optional provisions.
Dental benefit contracts may contain the following provisions:
1. A provision including the dental plan organization's intention to charge aspecified missed appointment fee. The fee shall be reasonable in relation tothe nature of the procedure for which the missed appointment had been made.Neither the plan dentist nor the dental plan organization may charge a missedappointment fee unless this provision appears in the dental benefit contract.For purposes of this section, the term "missed appointment" means anappointment for which advance cancellation of at least 24 hours was notprovided.
2. A provision including the dental plan organization's ability to increasepremiums or subscription fees, with this provision indicating that these feesmay not be increased unless:
a. The contract holder has been given written notice at least 60 days beforethe effective date of the increase; and
b. In the case of:
(1) An individual contract, present rates under the contract have not beenchanged for at least 12 months, or
(2) A group contract, present rates under the contract have been in effectfor at least 12 months.
3. A provision including the dental plan organization's intention to impose afinancial penalty on an enrollee for voluntarily withdrawing from the dentalplan during the first year of coverage, which penalty may not:
a. Be charged if the enrollee withdraws from the dental plan after beingcovered for at least 12 months; or
b. Exceed the usual, customary, and reasonable charge for services receivedreduced by the sum of the subscription fees paid by or for the enrollee andany copayments paid by or for the enrollee.
4. A provision including the dental plan organization's ability to increasethe patient charge schedule, with the provision indicating that the increasemay not be effective unless the:
a. Present schedule under the contract has been in effect for at least 12months; and
b. Contract holder has been given written notice of the increase at least 60days before the effective date of the increase.
5. A provision including the dental plan organization's rights if an enrolleerefuses to follow a particular course of treatment. The dental planorganization may not terminate the membership of an enrollee for refusal tofollow a recommended course of treatment for a particular condition. Theprovision may indicate that the dental plan organization may refuse toprovide any further benefits for the particular condition if the enrolleerefuses to accept a recommended course of treatment.
6. A provision including the dental plan organization's rights if an enrolleefraudulently uses his membership card or knowingly permits his membershipcard to be used by others. The dental plan organization may terminate anenrollee's coverage if the enrollee fraudulently uses his membership card orknowingly permits his membership card to be used by others. The dental planorganization may not terminate coverage for an entire family because adependent fraudulently uses the membership card. In this instance, only thedependent's coverage may terminate.
7. A provision specifying that the dental plan organization may terminate anenrollee's coverage if the enrollee is unable to maintain a satisfactorydentist-patient relationship with a plan dentist, provided, however:
a. Before terminating the enrollee's coverage, the dental plan organizationshall permit the enrollee to change primary dentists at least once;
b. The enrollee shall be given written notice of the termination at least 30days before the termination of the enrollee's membership.
8. If the contract provides coverage for dependent children, the contractshall also contain the following provision:
"Notwithstanding any limiting age stated in the contract, any unmarriedchild covered under the contract as a dependent of an enrollee who is chieflydependent for support upon the enrollee, and who, at the time of reaching thelimiting age, is incapable of self-support because of mental or physicalincapacity 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 onthe enrollee upon whom the child is dependent terminates."
(2004, c. 668.)