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.