By Harris S.B. No. 464 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.