On July 1, 2022, Indiana’s Non-Covered Services (NCS) statute went into effect. When the bill passed, Indiana joined 41 other states in prohibiting insurance companies from setting fees for services that they chose not to include as covered benefits in their plan. This protection against insurance company overreach is great news for dentists, but it has raised numerous questions regarding how it will affect the claims payment process. And the answers to those questions are not as simple as we would like. Here are just a few of them:
If I’m not contracted with a PPO, how does it affect me?
It doesn’t. The bill only impacts you if you signed a PPO contract agreeing to the insurance company’s payment terms.
I participate in a PPO that limits what I can charge for Non-Covered Services. Does this mean that I can now charge my regular fee?
Maybe. The new law regulates plans subject to Indiana law. Many self-insured plans claim they are exempt from the state law and are instead regulated by federal ERISA law. So there may still be limits on what your contract allows you to charge patients covered by a self-insured plan.
How do I know if a plan is fully-insured and subject to the NCS rule, or self-insured and exempt from the new law?
You don’t. Self-insured plans are often administered by well-known insurance companies. Some companies indicate on the patient’s ID card whether the plan is self-insured, but not all of them. At least for the first claim after July 1, it may be worth calling the insurance company for each patient covered by a plan that has limited NCS payment. Once you determine whether the patient is a fully-insured or self-insured plan, you will better know if the NCS law applies.
Why doesn’t the ADA change federal law to make self-insured plans subject to NCS laws?
We’re working on it. In fact, the passage of Indiana’s NCS law gives the ADA a stronger argument in making its case to congress. Now that 42 states have implemented NCS rules, it’s time for federally regulated plans to do the same.
Are there other exceptions to the new NCS law?
Yes. The law only affects procedures that are not covered by a fully-insured plan. You may still be required to accept the discounted fee as payment in full if a service is covered, but exceeds plan limits. For instance, if a plan covers two dental cleanings per year and you provide a third, the insurance company can likely limit your fee for the third procedure to the amount prescribed in the provider contract. In this case, the procedure is covered, but subject to other contract limitations. Similarly, if a patient has maxed out their annual maximum benefit, the discount will likely still apply to procedures that were covered, but denied due to exceeding the maximum annual benefit.
Is there a rule of thumb?
Ask yourself the question, “Is this service ever covered, or never covered?” If the procedure is ever covered, it likely falls within the exceptions laid out in the law and the insurance contract can still limit the fee you can charge. This would include services that are not allowed because of plan limitations such as deductibles, copayments, waiting periods or annual or lifetimes maximum benefits. But if the procedure is never covered, for instance, for most cosmetic procedures, then the NCS law will likely allow you to charge your regular fee.
How can I learn more about Indiana’s NCS law?
The new statue may be found in its entirety here. For specific questions, contact IDA Director of Government Affairs Shane Springer or Director of Professional Services Ed Rosenbaum. Both can be reached at 800-562-5646.
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