By: Haley S.B. No. 459
73R3497 PB-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to dental care benefits.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Article 21.53, Insurance Code, is amended by
1-5 amending Section 2 and by adding Sections 8, 9, and 10 to read as
1-6 follows:
1-7 Sec. 2. (a) No health insurance policy or employee benefit
1-8 plan which is delivered, renewed, issued for delivery, or otherwise
1-9 contracted for in this state shall:
1-10 (1) <(a)> prevent any person who is a party to or
1-11 beneficiary of any such health insurance policy or employee benefit
1-12 plan from selecting the dentist of his choice, including a dentist
1-13 to whom the person is related by affinity or consanguinity, to
1-14 furnish the dental care services offered by said policy or plan or
1-15 interfere with said selection provided the dentist is licensed to
1-16 furnish such dental care services in this state;
1-17 (2) <(b)> deny any dentist the right to participate as
1-18 a contracting provider for such policy or plan provided the dentist
1-19 is licensed to furnish the dental care services offered by said
1-20 policy or plan;
1-21 (3) <(c)> authorize any person to regulate, interfere,
1-22 or intervene in any manner in the diagnosis or treatment rendered
1-23 by a dentist to his patient for the purpose of preventing,
1-24 alleviating, curing, or healing dental illness or injury provided
2-1 said dentist practices within the scope of his license; <or>
2-2 (4) <(d)> require that any dentist furnishing dental
2-3 care services must make or obtain dental x-rays or any other
2-4 diagnostic aids for the purpose of preventing, alleviating, curing,
2-5 or healing dental illness or injury; provided, however, that
2-6 nothing herein shall prohibit requests for existing dental x-rays
2-7 or any other existing diagnostic aids for the purpose of
2-8 determining benefits payable under a health insurance policy or
2-9 employee benefit plan; or
2-10 (5) exclude or reduce the payment of benefits to or on
2-11 behalf of a beneficiary of a health insurance policy or employee
2-12 benefit plan because benefits are also payable or have been paid
2-13 under another health insurance policy or employee benefit plan
2-14 unless the amount of the total benefits paid to or on behalf of the
2-15 beneficiary is at least equal to 100 percent of the cost of the
2-16 dental care services.
2-17 (b) Nothing herein shall prohibit the predetermination of
2-18 benefits for dental care expenses prior to treatment by the
2-19 attending dentist. A benefit for dental care expenses may not be
2-20 reduced or otherwise denied in whole or in part solely because a
2-21 predetermination of benefits was not obtained prior to treatment.
2-22 Sec. 8. (a) Notwithstanding any other provision of this
2-23 article, the treatment profiles of an individual dentist prepared
2-24 by or at the direction of any person providing a health insurance
2-25 policy or employee benefit plan are confidential and may not be
2-26 disclosed, in whole or in part, to a third party or to a patient of
2-27 the dentist.
3-1 (b) A treatment profile that indicates the overuse of
3-2 certain procedures or procedure codes by a dentist may not be used
3-3 as a basis for denying or reducing benefits for dental care
3-4 services.
3-5 Sec. 9. (a) A person who, under a health insurance policy
3-6 or employee benefit plan, issues bulk payments to dentists for
3-7 providing covered dental care services shall include the following
3-8 information on the bulk payment check:
3-9 (1) the first and last name of the insured or
3-10 beneficiary;
3-11 (2) the first and last name of the patient, if
3-12 different from that of the insured or beneficiary;
3-13 (3) the dates of services to which the payment
3-14 applies;
3-15 (4) the specific treatment reported on the submitted
3-16 claim to which the payment applies identified by procedure code
3-17 number and nomenclature;
3-18 (5) the total fee charged;
3-19 (6) the total covered benefit;
3-20 (7) the total amount paid; and
3-21 (8) if the total covered benefit paid is less than the
3-22 total fee charged, an explanation of the reasons it is less.
3-23 (b) A person who issues bulk payments subject to Subsection
3-24 (a) of this section may not withhold payments that are currently
3-25 due and owing to a dentist as a means of resolving a dispute over a
3-26 prior unrelated benefit claim.
3-27 (c) A person who issues bulk payments shall issue the
4-1 payments to dentists at intervals of not more than 10 business
4-2 days.
4-3 Sec. 10. The board by rule shall provide for coordination of
4-4 benefits among all health insurance policies and employee benefit
4-5 plans under which benefits for dental care services are not
4-6 excluded or reduced because benefits are also payable or have been
4-7 paid under another health insurance policy or employee benefit plan
4-8 unless the amount of the total benefits paid to or on behalf of the
4-9 beneficiary are at least equal to 100 percent of the cost of the
4-10 dental care services.
4-11 SECTION 2. This Act takes effect September 1, 1993, and
4-12 applies only to a health insurance policy or employee benefit plan
4-13 that is delivered, issued for delivery, or renewed on or after
4-14 January 1, 1994. A policy or plan that is delivered, issued for
4-15 delivery, or renewed before January 1, 1994, is governed by the law
4-16 as it existed immediately before the effective date of this Act,
4-17 and that law is continued in effect for that purpose.
4-18 SECTION 3. The importance of this legislation and the
4-19 crowded condition of the calendars in both houses create an
4-20 emergency and an imperative public necessity that the
4-21 constitutional rule requiring bills to be read on three several
4-22 days in each house be suspended, and this rule is hereby suspended.