A new patient calls your office. 

They schedule an appointment. They arrive early. They complete their HIPAA forms, medical history, financial policy, and consent documents. Your team verifies insurance. Everything looks routine. 

You evaluate the patient and discuss their treatment needs. 

Let’s say it’s a core buildup and crown, or a periodontal maintenance visit beyond frequency limits, services that are commonly not covered by dental plans. 

You have a clear conversation: 

• The service may not be covered 

• The patient agrees to pay out-of-pocket 

• You proceed with treatment 

This is how dentistry is supposed to work: transparent, patient-centered, and based on mutual agreement. 

And in New Jersey, the law supports that. 

Under New Jersey law (N.J.S.A. 26:2S-33.1 and related statutes), dentists are permitted to: 

• Charge their usual and customary fees when coverage is uncertain, and 

• Refund patients later if insurance determines coverage differently 

New Jersey has also enacted protections to prevent insurers from forcing dentists to accept discounted fees for non-covered services. 

But then the Explanation of Benefits (EOB) arrives. 

And everything changes. 

When the Rules Change After the Fact 

A real example highlights the issue: 

A dentist receives an EOB showing a $400 adjustment for a service that was not covered under the patient’s plan. 

The explanation states: 

• The plan is self-funded and governed by ERISA 

• The service is not a covered benefit 

• The dentist cannot bill the full fee 

• The patient’s responsibility is limited, not by agreement, but by the dental plan 

Even though: 

• The patient agreed to pay 

• The service was not covered 

• New Jersey law would otherwise allow the dentist to charge their full fee 

The adjustment is enforced. 

This is the moment many dentists call NJDA. 

Why This Keeps Happening 

NJDA hears from members every week about the challenges of working with dental benefit payers. 

Many of those frustrations involve self-funded plans governed by the Employee Retirement Income Security Act of 1974 (ERISA). 

Members tell us: 

• Insurance cards and patient information often don’t distinguish whether a plan is self-funded or fully insured 

• Even when offices call carriers, representatives often cannot confirm plan type in real time 

• The EOB is often the first place the plan is identified as self-funded, after care has already been delivered 

• “Allowed fee for non-covered services” provisions force practices to take discounted fees simply because a plan is self-insured 

These protections are designed to safeguard the doctor-patient relationship and promote fairness and transparency. 

But when ERISA plans are allowed to bypass these laws, it creates a system where: 

• Patients receive inconsistent protections 

• Dentists face unpredictable rules 

• Access to care is affected 

From Member Calls to Congressional Action 

When these issues arise, members call NJDA. 

And when we hear those concerns, we work with our colleagues across organized dentistry to ensure those voices reach policymakers. 

NJDA and other state dental associations have been working with the American Dental Association to elevate these concerns at the federal level. 

Now, that advocacy is taking shape in Congress. 

On March 12, Representatives Jeff Van Drew, D.M.D., and Herb Conaway, M.D., both of New Jersey, introduced the Improving Dental Administration Act, legislation aimed at ensuring that state dental insurance reform laws apply to self-funded dental plans. 

This legislation reflects the real experiences of dentists navigating ERISA plan loopholes and is an important step toward restoring fairness and transparency in dental benefits administration. 

Why Political Action and Relationships Matter 

This is what advocacy in organized dentistry looks like and why building relationships through political action is so important. 

This moment did not happen overnight. 

For years, NJDA members have: 

• Participated in Lobby Day visits 

• Shared real-world experiences with policymakers 

• Supported leaders through NJDPAC and ADPAC 

Both sponsors of this bipartisan bill — Dr. Van Drew and Dr. Conaway — have long-standing relationships with organized dentistry. They have heard directly from dentists and understand the challenges facing the profession.