HR1521-119

1. Short title This Act may be cited as the Dental and Optometric Care Access Act of 2025 or the DOC Access Act of 2025.

2. Improving health care coverage under vision and dental plans Title XXVII of the Public Health Service Act is amended by inserting after section 2719A (42 U.S.C. 300gg–19a) the following new section: Under a group health plan or individual or group health insurance coverage (including such a plan or coverage offering limited scope dental or vision benefits), the following shall apply: The plan or coverage shall provide that, with respect to a doctor of optometry, doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor that has an agreement to participate in the plan or coverage and that provides items or services within the scope of practice of such a doctor that are not covered services under the plan or coverage to a person enrolled under such plan or coverage, such doctor or entity may charge the enrollee for such items or services any amount determined by such doctor or entity that is equal to, or less than, the usual and customary amount that such doctor or entity charges individuals who are not so enrolled for such items or services. For purposes of subparagraph (A), an item or service shall be considered, with respect to a plan or coverage, to be covered services under the plan or coverage only if the item or service is an item or service with respect to which the plan or coverage is obligated to pay an amount that is reasonable and is not nominal or de minimis. For purposes of subparagraph (A), a doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor that has an agreement to participate in the plan or coverage may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan or coverage. In the case of an agreement between such a doctor or entity and such a plan or coverage that offers limited scope dental or vision benefits— the agreement may be extended for a term longer than 2 years only with the prior acceptance of such doctor or entity for each such term extension; and the agreement may be extended for unlimited terms, subject to subparagraph (A). The plan or coverage may not, directly or indirectly, restrict or limit the laboratory or source or supplier of services or materials that such a doctor or entity may choose with respect to items and services within the scope of practice of such a doctor that are provided by such doctor or entity to an individual enrolled under the plan or coverage. The Secretary shall on an annual basis notify each State of the State’s authority to enforce the provisions of subsection (a) against a group health plan or health insurance coverage described in subsection (a) pursuant to section 2723(a)(1) and request confirmation from the State whether or not the State will enforce the provisions of subsection (a). If a State notifies the Secretary that the State will not enforce the provisions of subsection (a) or fails to respond within 90 days of the Secretary’s request, the Secretary shall treat such State as failing to substantially enforce such provisions for purposes of subsections (a)(2) and (b) of section 2723. Section 2722(c)(1) shall not apply with respect to the requirements of this section. If a doctor of optometry, doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan or coverage shall not apply to such plan or coverage for such period, as described in paragraph (2). An election under paragraph (1)— shall apply for a single specified plan year; may be extended through subsequent elections under this subsection; and shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). In this section: The term covered services means dental care or vision care services for which reimbursement is available under a plan or coverage contract, or for which reimbursement would be available but for the application of contractual limitations, including deductibles, copayments, coinsurance, waiting periods, lifetime maximum, frequency limitations, and alternative benefit payments. The terms doctor of dental surgery and doctor of dental medicine mean a doctor of dental surgery or of dental medicine, as applicable, who is legally authorized to practice dentistry by the State in which the doctor performs such function and who is acting within the scope of the license of the doctor when performing such functions. The term doctor of optometry means a doctor of optometry who is legally authorized to practice optometry by the State in which the doctor so practices. Section 2722(c)(1) of the Public Health Service Act (42 U.S.C. 300gg–21(c)(1)) is amended by striking The requirements and inserting Subject to section 2719B, the requirements. Notwithstanding any amendment made by this Act, State law that directly affects any standard or requirement relating to health insurance issuers and dental or vision benefit plans shall have exclusive application and the amendments made by this Act shall not apply to the extent that such State law conflicts with such amendments. The State shall retain exclusive jurisdiction over health insurance issuers and limited scope dental or vision benefit plans that are directly governed by such State. 2719B.Improving coverage under vision and dental plans (a)In generalUnder a group health plan or individual or group health insurance coverage (including such a plan or coverage offering limited scope dental or vision benefits), the following shall apply: (1)Payment amounts from covered persons (A)In generalThe plan or coverage shall provide that, with respect to a doctor of optometry, doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor that has an agreement to participate in the plan or coverage and that provides items or services within the scope of practice of such a doctor that are not covered services under the plan or coverage to a person enrolled under such plan or coverage, such doctor or entity may charge the enrollee for such items or services any amount determined by such doctor or entity that is equal to, or less than, the usual and customary amount that such doctor or entity charges individuals who are not so enrolled for such items or services. (B)Items or services considered covered by a planFor purposes of subparagraph (A), an item or service shall be considered, with respect to a plan or coverage, to be covered services under the plan or coverage only if the item or service is an item or service with respect to which the plan or coverage is obligated to pay an amount that is reasonable and is not nominal or de minimis. (C)Exception for dental cleaningFor purposes of subparagraph (A), a doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor that has an agreement to participate in the plan or coverage may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan or coverage. (2)Duration of limited scope vision and dental plansIn the case of an agreement between such a doctor or entity and such a plan or coverage that offers limited scope dental or vision benefits— (A)the agreement may be extended for a term longer than 2 years only with the prior acceptance of such doctor or entity for each such term extension; and (B)the agreement may be extended for unlimited terms, subject to subparagraph (A). (3)No restrictions on choice of laboratoriesThe plan or coverage may not, directly or indirectly, restrict or limit the laboratory or source or supplier of services or materials that such a doctor or entity may choose with respect to items and services within the scope of practice of such a doctor that are provided by such doctor or entity to an individual enrolled under the plan or coverage. (b)NotificationThe Secretary shall on an annual basis notify each State of the State’s authority to enforce the provisions of subsection (a) against a group health plan or health insurance coverage described in subsection (a) pursuant to section 2723(a)(1) and request confirmation from the State whether or not the State will enforce the provisions of subsection (a). If a State notifies the Secretary that the State will not enforce the provisions of subsection (a) or fails to respond within 90 days of the Secretary’s request, the Secretary shall treat such State as failing to substantially enforce such provisions for purposes of subsections (a)(2) and (b) of section 2723. (c)Relationship to exception for limited, excepted benefitsSection 2722(c)(1) shall not apply with respect to the requirements of this section. (d)Election To be excluded (1)In generalIf a doctor of optometry, doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan or coverage shall not apply to such plan or coverage for such period, as described in paragraph (2). (2)Period of electionAn election under paragraph (1)— (A)shall apply for a single specified plan year; (B)may be extended through subsequent elections under this subsection; and (C)shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). (e)DefinitionsIn this section: (1)The term covered services means dental care or vision care services for which reimbursement is available under a plan or coverage contract, or for which reimbursement would be available but for the application of contractual limitations, including deductibles, copayments, coinsurance, waiting periods, lifetime maximum, frequency limitations, and alternative benefit payments. (2)The terms doctor of dental surgery and doctor of dental medicine mean a doctor of dental surgery or of dental medicine, as applicable, who is legally authorized to practice dentistry by the State in which the doctor performs such function and who is acting within the scope of the license of the doctor when performing such functions. (3)The term doctor of optometry means a doctor of optometry who is legally authorized to practice optometry by the State in which the doctor so practices..

2719B. Improving coverage under vision and dental plans Under a group health plan or individual or group health insurance coverage (including such a plan or coverage offering limited scope dental or vision benefits), the following shall apply: The plan or coverage shall provide that, with respect to a doctor of optometry, doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor that has an agreement to participate in the plan or coverage and that provides items or services within the scope of practice of such a doctor that are not covered services under the plan or coverage to a person enrolled under such plan or coverage, such doctor or entity may charge the enrollee for such items or services any amount determined by such doctor or entity that is equal to, or less than, the usual and customary amount that such doctor or entity charges individuals who are not so enrolled for such items or services. For purposes of subparagraph (A), an item or service shall be considered, with respect to a plan or coverage, to be covered services under the plan or coverage only if the item or service is an item or service with respect to which the plan or coverage is obligated to pay an amount that is reasonable and is not nominal or de minimis. For purposes of subparagraph (A), a doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor that has an agreement to participate in the plan or coverage may charge an enrollee only the contracted network fee for any dental cleaning, including any dental cleaning that exceeds the annual maximum under the enrollee’s plan or coverage. In the case of an agreement between such a doctor or entity and such a plan or coverage that offers limited scope dental or vision benefits— the agreement may be extended for a term longer than 2 years only with the prior acceptance of such doctor or entity for each such term extension; and the agreement may be extended for unlimited terms, subject to subparagraph (A). The plan or coverage may not, directly or indirectly, restrict or limit the laboratory or source or supplier of services or materials that such a doctor or entity may choose with respect to items and services within the scope of practice of such a doctor that are provided by such doctor or entity to an individual enrolled under the plan or coverage. The Secretary shall on an annual basis notify each State of the State’s authority to enforce the provisions of subsection (a) against a group health plan or health insurance coverage described in subsection (a) pursuant to section 2723(a)(1) and request confirmation from the State whether or not the State will enforce the provisions of subsection (a). If a State notifies the Secretary that the State will not enforce the provisions of subsection (a) or fails to respond within 90 days of the Secretary’s request, the Secretary shall treat such State as failing to substantially enforce such provisions for purposes of subsections (a)(2) and (b) of section 2723. Section 2722(c)(1) shall not apply with respect to the requirements of this section. If a doctor of optometry, doctor of dental surgery, doctor of dental medicine, or entity that employs such a doctor to which the provisions of paragraphs (1) and (3) of subsection (a) otherwise apply makes an election under this paragraph (in such form and manner as the Secretary may by regulations prescribe), the requirements of such paragraphs insofar as they apply directly to the plan or coverage shall not apply to such plan or coverage for such period, as described in paragraph (2). An election under paragraph (1)— shall apply for a single specified plan year; may be extended through subsequent elections under this subsection; and shall not be available with respect to the requirements concerning the duration of limited scope vision and dental plans under subsection (a)(2). In this section: The term covered services means dental care or vision care services for which reimbursement is available under a plan or coverage contract, or for which reimbursement would be available but for the application of contractual limitations, including deductibles, copayments, coinsurance, waiting periods, lifetime maximum, frequency limitations, and alternative benefit payments. The terms doctor of dental surgery and doctor of dental medicine mean a doctor of dental surgery or of dental medicine, as applicable, who is legally authorized to practice dentistry by the State in which the doctor performs such function and who is acting within the scope of the license of the doctor when performing such functions. The term doctor of optometry means a doctor of optometry who is legally authorized to practice optometry by the State in which the doctor so practices.