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.