By Berlanga H.B. No. 1244
75R4696 DLF-F
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to providing fairness and choice to certain patients and
1-3 providers under managed care health benefit plans.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Chapter 21, Insurance Code, is amended by adding
1-6 Subchapter G to read as follows:
1-7 SUBCHAPTER G. DENTAL PATIENT ASSURANCE ACT
1-8 Art. 21.101. SHORT TITLE. This subchapter may be cited as
1-9 the Dental Patient Assurance Act.
1-10 Art. 21.102. DEFINITIONS. In this subchapter:
1-11 (1) "Commissioner" means the Commissioner of
1-12 Insurance.
1-13 (2) "Dentist" means a person licensed to practice
1-14 dentistry by the State Board of Dental Examiners.
1-15 (3) "Department" means the Texas Department of
1-16 Insurance.
1-17 (4) "Emergency dental services" means dental services
1-18 provided for an emergency dental condition.
1-19 (5) "Emergency dental condition" means a dental
1-20 condition manifesting itself by acute symptoms, such as severe
1-21 pain, of sufficient severity so that the absence of immediate
1-22 dental attention could reasonably be expected to result in:
1-23 (A) serious jeopardy to the health of the
1-24 individual;
2-1 (B) serious impairment to a bodily function; or
2-2 (C) serious dysfunction of an organ or part of
2-3 the body.
2-4 (6) "Managed care entity" means a health maintenance
2-5 organization licensed under the Texas Health Maintenance
2-6 Organization Act (Chapter 20A, Vernon's Texas Insurance Code), a
2-7 preferred provider organization, or another organization that
2-8 provides for the financing and delivery of health care or dental
2-9 services to persons enrolled in a coverage plan offered by the
2-10 entity through:
2-11 (A) arrangements with selected dentists to
2-12 furnish health or dental care services;
2-13 (B) explicit standards for the selection of
2-14 participating dentists;
2-15 (C) organizational arrangements for ongoing
2-16 quality assurance, utilization review, and dispute resolution; or
2-17 (D) differential coverage or payments or
2-18 financial incentives for a person enrolled in the plan to use the
2-19 participating dentists and procedures provided by the plan.
2-20 (7) "Managed care plan" means a plan of health care
2-21 coverage offered by a managed care entity. The term does not
2-22 include accident-only, specified disease, individual hospital
2-23 indemnity, credit, vision only, Medicare supplement or Medicare
2-24 Select, long-term care, disability income, CHAMPUS supplement, or
2-25 workers' compensation insurance, insurance coverage issued as a
2-26 supplement to liability insurance or other similar insurance, or
2-27 automobile medical payment insurance.
3-1 (8) "Prospective enrollee" means an individual
3-2 applying for enrollment in a managed care plan or eligible for
3-3 enrollment in a group managed care plan.
3-4 Art. 21.103. STANDARDS. The commissioner by rule may adopt
3-5 standards to ensure compliance with this subchapter by managed care
3-6 entities that conduct business in this state.
3-7 Art. 21.104. POINT-OF-SERVICE OFFERING. (a) A managed care
3-8 entity shall provide an optional point-of-service plan as part of a
3-9 managed care plan.
3-10 (b) If the managed care plan is offered to an enrollee
3-11 through an employer-sponsored benefit plan, any additional costs
3-12 for the point-of-service plan are the responsibility of the
3-13 enrollee and the employer may impose a reasonable administrative
3-14 fee for providing the optional point-of-service plan. The
3-15 department may review an administrative fee imposed under this
3-16 subsection, and the commissioner may by order require the employer
3-17 to lower the fee if the commissioner finds that the fee is not
3-18 reasonable. As an alternative to a point-of-service plan, an
3-19 employer may offer enrollees a direct reimbursement program. An
3-20 employer that offers a direct reimbursement program is not
3-21 otherwise subject to this article.
3-22 (c) If a managed care entity offers a point-of-service plan
3-23 in its service area and is the only entity providing services under
3-24 a health benefit plan, it must offer to all eligible enrollees the
3-25 opportunity to obtain coverage for out-of-network services through
3-26 the point-of-service plan at the time of enrollment and at least
3-27 annually.
4-1 (d) The premium for the point-of-service plan must be based
4-2 on the actuarial value of that coverage.
4-3 (e) In this article:
4-4 (1) "Direct reimbursement program" means a program
4-5 under which an enrollee is reimbursed from a contribution fund
4-6 based on a percentage of dollars spent for dental care provided
4-7 that is funded by employer or employee contributions and that
4-8 allows an enrollee to obtain dental treatment from the dentist of
4-9 the enrollee's choice.
4-10 (2) "Point-of-service plan" means a plan provided
4-11 through a contractual arrangement under which indemnity benefits
4-12 for the cost of health or dental care services, other than
4-13 emergency care or emergency dental care, are provided by an insurer
4-14 or group hospital service corporation in conjunction with
4-15 corresponding benefits arranged or provided by a managed care
4-16 entity. An enrollee may choose to obtain benefits or services
4-17 under either the indemnity plan or managed care plan in accordance
4-18 with specific provisions of a point-of-service contract.
4-19 Art. 21.105. ENROLLEE INFORMATION. (a) A managed care
4-20 entity shall provide a prospective enrollee a written description
4-21 of the terms and conditions of the managed care plan. The written
4-22 plan description must be in a readable and understandable format
4-23 and must include:
4-24 (1) coverage provisions;
4-25 (2) benefits, including generic and brand name
4-26 prescription drug coverage;
4-27 (3) any exclusions by category of service, by type of
5-1 dentist, and, if applicable, by specific service or types of drugs;
5-2 (4) any required prior authorization for benefits,
5-3 including:
5-4 (A) procedures for and limitations or
5-5 restrictions on referrals to other dentists; or
5-6 (B) other review requirements, including
5-7 preauthorization review, concurrent review, postservice review, and
5-8 postpayment review;
5-9 (5) an explanation of enrollee financial
5-10 responsibility for payment for coinsurance or other noncovered or
5-11 out-of-plan services;
5-12 (6) a disclosure to prospective enrollees that
5-13 includes the following language:
5-14 "YOUR RIGHTS UNDER TEXAS LAW:
5-15 "You have the right to information about the plan, including
5-16 how the plan operates, what general types of financial arrangements
5-17 exist between dentists and the plan, names and locations of
5-18 dentists participating in the plan, the numbers of enrollees and
5-19 dentists in the plan, the percentage of premiums allocated for
5-20 dental care, administrative costs, and profit, and an explanation
5-21 of the benefits to which enrollees are entitled under the terms of
5-22 the plan."; and
5-23 (7) a phone number and address for the prospective
5-24 enrollee to obtain additional information concerning the items
5-25 described by the disclosure required by this subsection.
5-26 (b) The managed care entity may provide the information
5-27 under Subsection (a)(6) of this article regarding the percentage of
6-1 premiums allocated for dental care, administrative costs, and
6-2 profit by providing the information included in the entity's annual
6-3 financial statement most recently submitted to the department.
6-4 (c) If the managed care plan uses a capitation method of
6-5 compensation, the plan must establish and follow procedures that
6-6 ensure that:
6-7 (1) each plan application form includes a space in
6-8 which each enrollee selects a dentist;
6-9 (2) each enrollee who fails to select a dentist and is
6-10 assigned a dentist is notified of the name and location of that
6-11 dentist;
6-12 (3) a dentist is assigned to each new enrollee not
6-13 later than the 30th day after the date the enrollee is enrolled;
6-14 and
6-15 (4) a dentist to whom an enrollee is assigned is
6-16 physically located within a reasonable travel distance, as
6-17 established by rule adopted by the commissioner, from the residence
6-18 or place of employment of the enrollee.
6-19 (d) A managed care entity that represents to an enrollee or
6-20 prospective enrollee that a dentist is a participant in a managed
6-21 care plan without the dentist's prior consent commits an unfair and
6-22 deceptive act in the business of insurance for purposes of Article
6-23 21.21 of this code.
6-24 Art. 21.106. FINANCIAL INCENTIVE PROGRAMS. A managed care
6-25 entity may not use a financial incentive or make a payment to a
6-26 dentist that acts directly or indirectly as an inducement to limit
6-27 dental services.
7-1 Art. 21.107. MANAGED DENTAL CARE ADMINISTRATION. (a) A
7-2 managed care entity shall make patient treatment and referral
7-3 decisions according to clinical guidelines developed and approved
7-4 by dentists from the same or a similar area of practice.
7-5 (b) A referral or review decision made under a managed care
7-6 plan must be made by a dentist. The managed care entity shall
7-7 provide a written procedure for an enrollee to appeal a denial of a
7-8 referral to a specialist.
7-9 Art. 21.108. HEALTH MAINTENANCE SERVICES. (a) A managed
7-10 care plan must include health maintenance services, including
7-11 prevention and wellness information and services. The health
7-12 maintenance services must be based on guidelines approved by the
7-13 commissioner. In approving guidelines under this section, the
7-14 commissioner shall consider guidelines established by the American
7-15 Dental Association and the American Medical Association.
7-16 (b) Each managed care entity at least annually shall notify
7-17 enrollees of the importance of obtaining preventive dental service
7-18 and shall maintain a record of providing this notice.
7-19 (c) A participating dentist shall maintain a record of
7-20 dental services provided to an enrollee and shall report the
7-21 services to the managed care entity.
7-22 (d) A managed care entity shall report the information
7-23 recorded under Subsections (b) and (c) of this section to the
7-24 department.
7-25 Art. 21.109. ENROLLEE COMPLAINT PROCEDURES. (a) The
7-26 commissioner by rule shall adopt standardized enrollee complaint
7-27 procedures in accordance with this section. The procedures shall
8-1 prescribe internal complaint procedures within a managed care plan
8-2 and include a procedure for subsequent appeals to the department on
8-3 exhaustion of internal complaint procedures.
8-4 (b) Each managed care entity shall use an appeals panel to
8-5 evaluate enrollee complaints. An appeals panel created under this
8-6 subsection must:
8-7 (1) include at least one dentist who has expertise in
8-8 the specific area of practice related to the appeal; and
8-9 (2) have one-half of its total membership composed of
8-10 enrollees who are not employed by the managed care entity and who
8-11 do not have another potential conflict of interest in the appeal.
8-12 (c) A managed care entity shall notify each enrollee in
8-13 writing of the complaint procedure during the solicitation of
8-14 enrollment, at the time of enrollment, and on the denial,
8-15 limitation, or termination of a service by the managed care entity.
8-16 (d) Except as provided by Subsection (e) of this section, a
8-17 managed care entity shall investigate and provide a written
8-18 resolution of an enrollee complaint not later than the 30th day
8-19 after the date the complaint is made, unless the managed care
8-20 entity and the enrollee agree to extend this period.
8-21 (e) The enrollee complaint process must provide for
8-22 expedited internal review of enrollee complaints regarding urgent
8-23 care that provides for review of the complaint and an oral or
8-24 written decision with respect to the complaint not later than 72
8-25 hours after the complaint is made.
8-26 (f) The enrollee may designate a dentist, a physician, or
8-27 any other individual to file a complaint on behalf of the enrollee.
9-1 (g) A managed care entity shall notify an enrollee in
9-2 writing of the reason for a denial, limitation, or termination of a
9-3 service provided or to be provided to the enrollee. The notice
9-4 must be made not later than the 30th day after the date of the
9-5 denial, limitation, or termination of the service and must identify
9-6 by name and position the individual who made the decision to deny,
9-7 limit, or terminate the service.
9-8 Art. 21.110. EMERGENCY SERVICES. A managed care plan shall
9-9 cover:
9-10 (1) emergency care services, including the treatment
9-11 and stabilization of an emergency dental condition, that are
9-12 provided to covered individuals, without regard to whether the
9-13 treating dentist has a contractual or other arrangement with the
9-14 entity to provide items or services to covered individuals;
9-15 (2) medically necessary services following treatment
9-16 or stabilization of an emergency dental condition that are provided
9-17 or initiated in a hospital emergency department without the prior
9-18 authorization of the managed care entity, unless within a
9-19 reasonable time appropriate to the circumstances, as determined by
9-20 the treating dentist, the managed care entity is notified and
9-21 denies coverage for the services; and
9-22 (3) any medical or dental screening examination to
9-23 determine whether an emergency dental condition exists and any
9-24 other evaluation required by state or federal law to be provided in
9-25 the emergency department of a hospital.
9-26 Art. 21.111. PRIOR AUTHORIZATION; CONSENT. A managed care
9-27 plan for which prior authorization is a condition to coverage of a
10-1 service must ensure that enrollees are required to sign medical and
10-2 dental information release consent forms on enrollment.
10-3 Art. 21.112. UTILIZATION REVIEW. A managed care plan is
10-4 subject to and shall meet the requirements of Article 21.58A of
10-5 this code.
10-6 SECTION 2. Section 26, Texas Health Maintenance Organization
10-7 Act (Section 20A.26, Vernon's Texas Insurance Code), is amended by
10-8 adding Subsection (j) to read as follows:
10-9 (j) A health maintenance organization is subject to
10-10 Subchapter G, Chapter 21, Insurance Code.
10-11 SECTION 3. This Act takes effect September 1, 1997, and
10-12 applies only to a managed care plan that is delivered, issued for
10-13 delivery, or renewed on or after January 1, 1998. A managed care
10-14 plan that is delivered, issued for delivery, or renewed before
10-15 January 1, 1998, is governed by the law as it existed immediately
10-16 before the effective date of this Act, and that law is continued in
10-17 effect for this purpose.
10-18 SECTION 4. The importance of this legislation and the
10-19 crowded condition of the calendars in both houses create an
10-20 emergency and an imperative public necessity that the
10-21 constitutional rule requiring bills to be read on three several
10-22 days in each house be suspended, and this rule is hereby suspended.