By Maxey H.B. No. 1363 75R3312 DLF-D A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to dental health maintenance organizations. 1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-4 SECTION 1. The Texas Health Maintenance Organization Act 1-5 (Chapter 20A, Vernon's Texas Insurance Code) is amended by 1-6 designating Sections 1-36 as Part A and by adding a heading for 1-7 Part A to read as follows: 1-8 PART A. GENERAL PROVISIONS 1-9 SECTION 2. The Texas Health Maintenance Organization Act 1-10 (Chapter 20A, Vernon's Texas Insurance Code) is amended by adding 1-11 Part B to read as follows: 1-12 PART B. DENTAL HEALTH MAINTENANCE ORGANIZATIONS 1-13 Sec. 51. EVIDENCE OF COVERAGE. (a) In addition to the 1-14 requirements of Section 9 of this Act (Article 20A.09, Vernon's 1-15 Texas Insurance Code), an evidence of coverage for a dental care 1-16 service plan must: 1-17 (1) specify the total charges to an enrollee for 1-18 typical sample office visits or procedures, such as an initial 1-19 office visit or a crown, extraction, or filling; 1-20 (2) list the procedures that represent at least 90 1-21 percent of the plan's value and state whether benefits are paid for 1-22 each of the listed procedures and the amount of the benefit paid 1-23 for each listed procedure; and 1-24 (3) include a glossary of dental terminology. 2-1 (b) The commissioner shall adopt rules governing the form 2-2 and content of the information required to be provided under this 2-3 section. 2-4 Sec. 52. INFORMATIONAL BROCHURE. (a) A dental health 2-5 maintenance organization shall prepare an informational brochure 2-6 that includes: 2-7 (1) a list of the 30 most commonly administered dental 2-8 procedures, a statement as to whether the dental care service plan 2-9 provides benefits for each of those procedures, the amount of 2-10 benefits paid for each procedure, and the amount the enrollee will 2-11 be required to pay for each procedure; 2-12 (2) a description of the limitations and exclusions 2-13 applicable to benefits; 2-14 (3) a description of any applicable limitations on 2-15 availability of appointments with participating dentists and, if 2-16 applicable, a statement of the average number of days an enrollee 2-17 waits for an appointment after requesting an appointment; 2-18 (4) if applicable, a description of the manner in 2-19 which charges and benefits for dental services are unbundled, so 2-20 that individual procedures that represent only part of the total 2-21 services required for a particular dental need may be separately 2-22 charged; and 2-23 (5) a description of the process by which an enrollee 2-24 may: 2-25 (A) make a complaint; or 2-26 (B) obtain review of a coverage or payment 2-27 decision of the dental health maintenance organization that is 3-1 adverse to the enrollee. 3-2 (b) At the time an enrollee is enrolled in a dental health 3-3 maintenance organization, the dental health maintenance 3-4 organization shall provide a copy of the brochure to the enrollee. 3-5 (c) The commissioner shall adopt rules that govern the form 3-6 and content of the information to be provided by the brochure 3-7 required by this section. 3-8 Sec. 53. REVIEW OF ADVERTISING; BROCHURE. (a) A dental 3-9 health maintenance organization may not use a brochure, including 3-10 the brochure described by Section 52 of this Act, or other written 3-11 material to market the dental care service plan to prospective 3-12 enrollees before: 3-13 (1) a copy of the brochure or other material is 3-14 approved by the commissioner; and 3-15 (2) a copy of the brochure or other material is mailed 3-16 or delivered to each participating dentist. 3-17 (b) A dental health maintenance organization may not use a 3-18 brochure, including the brochure described by Section 52 of this 3-19 Act, or other written material to market the dental care service 3-20 plan to prospective enrollees if the brochure or material: 3-21 (1) is false, deceptive, or misleading; or 3-22 (2) states the amount of a discount for dental 3-23 services provided under the dental care service plan, unless the 3-24 total fee from which the discount is taken is also stated. 3-25 (c) A brochure or other material filed with the commissioner 3-26 is considered approved by the commissioner unless the commissioner, 3-27 before the 30th day after the date the brochure or other material 4-1 is filed, issues an order: 4-2 (1) denying approval of the brochure or other 4-3 material; or 4-4 (2) extending the period for the commissioner to act 4-5 under this subsection. 4-6 (d) The commissioner may withdraw approval of a brochure or 4-7 other material filed with the commissioner if the commissioner 4-8 finds, after notice and hearing, that the brochure or other 4-9 material does not comply with this Act, another insurance law of 4-10 this state, or rules adopted by the commissioner. 4-11 Sec. 54. REVIEW OF USE. (a) Each dental health maintenance 4-12 organization shall review the use of dental care services covered 4-13 under the dental care service plan and shall annually report to the 4-14 department regarding the use of those services. The report must 4-15 state: 4-16 (1) the number of individuals using services covered 4-17 under the dental care service plan and the percentage of enrollees 4-18 using the services; 4-19 (2) the number of families enrolled in the plan; 4-20 (3) for each category of services provided, the total 4-21 number and value of services provided; 4-22 (4) for each category of services provided, the 4-23 percentage of the total number of all services provided and the 4-24 percentage of the total value of all services provided that the 4-25 category of services represents; 4-26 (5) the number of enrollee dental care visits; 4-27 (6) the average number of dental care visits for an 5-1 enrollee in a year and the average benefit paid, assuming a usual, 5-2 reasonable, and customary benefit for each visit; 5-3 (7) the number of recommended referrals made by 5-4 participating dentists to specialists, by type of speciality; 5-5 (8) the number of referrals described by Subdivision 5-6 (7) of this subsection that were not approved by the dental health 5-7 maintenance organization; and 5-8 (9) the percentage of enrollees who terminate coverage 5-9 under the dental care service plan in any year. 5-10 (b) The commissioner may adopt rules regarding the form and 5-11 content of the report required by this section and the date by 5-12 which the report must be filed. 5-13 Sec. 55. SATISFACTION SURVEY. (a) Each dental health 5-14 maintenance organization shall annually conduct a survey of 5-15 enrollees to determine the enrollees' level of satisfaction with 5-16 the dental care service plan. The dental health maintenance 5-17 organization shall file the results of the survey with the 5-18 department. 5-19 (b) The survey must be conducted in accordance with rules 5-20 adopted by the commissioner. The rules shall state the date by 5-21 which the survey results must be filed. 5-22 SECTION 3. Section 2, Texas Health Maintenance Organization 5-23 Act (Section 20A.02, Vernon's Texas Insurance Code), is amended by 5-24 adding Subsections (v), (w), and (x) to read as follows: 5-25 (v) "Dental health maintenance organization" means a health 5-26 maintenance organization that offers a dental care service plan. 5-27 (w) "Dental care service plan" means a single health care 6-1 service plan for dental services. 6-2 (x) "Participating dentist" means a dentist who contracts 6-3 with a dental health maintenance organization to provide dental 6-4 services under a dental care service plan. 6-5 SECTION 4. (a) This Act applies only to an evidence of 6-6 coverage that is delivered, issued for delivery, or renewed by a 6-7 dental health maintenance organization on or after January 1, 1998. 6-8 An evidence of coverage that is delivered, issued for delivery, or 6-9 renewed before January 1, 1998, is governed by the law as it 6-10 existed immediately before the effective date of this Act, and that 6-11 law is continued in effect for this purpose. 6-12 (b) This Act applies only to a brochure or other written 6-13 material used to market a dental care service plan by a dental 6-14 health maintenance organization on or after January 1, 1998. A 6-15 brochure or other material used before January 1, 1998, is governed 6-16 by the law as it existed immediately before the effective date of 6-17 this Act, and that law is continued in effect for this purpose. 6-18 (c) A dental health maintenance organization is not required 6-19 to make the reports required under Sections 54 and 55, Texas Health 6-20 Maintenance Organization Act (Chapter 20A, Vernon's Texas Insurance 6-21 Code), as added by this Act, before September 1, 1998. 6-22 SECTION 5. This Act takes effect September 1, 1997. 6-23 SECTION 6. The importance of this legislation and the 6-24 crowded condition of the calendars in both houses create an 6-25 emergency and an imperative public necessity that the 6-26 constitutional rule requiring bills to be read on three several 6-27 days in each house be suspended, and this rule is hereby suspended.