BILL ANALYSIS

 

 

 

C.S.H.B. 2486

By: Goldman

Insurance

Committee Report (Substituted)

 

 

 

BACKGROUND AND PURPOSE

 

It has been suggested that dental patients and dentists need timely and accurate information about benefits to verify patients' enrollment, eligibility, and scope of benefits. C.S.H.B. 2486 seeks to address this issue by requiring certain entities to use a website to make more patient and benefit information available to patients and certain health care providers.

 

CRIMINAL JUSTICE IMPACT

 

It is the committee's opinion that this bill does not expressly create a criminal offense, increase the punishment for an existing criminal offense or category of offenses, or change the eligibility of a person for community supervision, parole, or mandatory supervision.

 

RULEMAKING AUTHORITY

 

It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency, or institution.

 

ANALYSIS

 

C.S.H.B. 2486 amends the Insurance Code to set out provisions applicable to employee benefit plans and health insurance policies that provide benefits for dental care services. The bill requires a person or entity who provides or issues such a plan or policy or the employer or employee organization, if applicable, to establish a website to provide resources and information to dentists, insureds, participants, employees, and members. The bill requires such a provider or issuer to make accessible on the website information about the plan or policy sufficient for patients and dentists to determine the following:

·         the type of dental care services covered by the plan or policy;

·         the percentage of the allowed charges for a covered service that will be paid or reimbursed under the plan or policy; and

·         for a contracting provider dentist, an estimate of the amount of the payment or reimbursement available for the provider's services under the plan or policy.

The bill requires access to the website to be at no charge to patients under the plan or policy and dentists providing dental care services to the patients.

 

C.S.H.B. 2486 requires an applicable plan or policy to provide one or more methods of payment or reimbursement that provide the dentist 100 percent of the contracted amount of the payment or reimbursement and that do not require the dentist to incur a fee to access the payment or reimbursement and to disclose on the website and on request of a dentist or a party to or beneficiary of the plan or policy the fees, if any, associated with the methods of payment or reimbursement available under the plan or policy.

 

C.S.H.B. 2486 prohibits an applicable plan or policy from deducting the amount of an overpayment of a claim from a payment or reimbursement for a dental care service provided by a dentist who did not receive the overpayment. The bill defines "predetermination" for purposes of a statutory provision establishing that prohibitions against certain conduct by a plan or policy do not prohibit the predetermination of benefits for dental care expenses before the attending dentist provides treatment.

 

C.S.H.B. 2486 requires an applicable provider or issuer to provide to a dentist, on request of the dentist or a patient, a written prior authorization of benefits for a dental care service for the patient for which a prior authorization is required. The bill requires the prior authorization to include a specific benefit payment or reimbursement amount and prohibits the provider or issuer, with certain exceptions, from paying or reimbursing the dentist in an amount less than the amount stated in the prior authorization. The bill sets out the conditions under which a provider or issuer that preauthorizes a dental care service may deny a claim for the dental care service or reduce payment or reimbursement to the dentist for the service. The bill defines "prior authorization" and establishes that the term includes preauthorization or similar authorization but does not include a predetermination, as defined by the bill.

 

EFFECTIVE DATE

 

September 1, 2019.

 

COMPARISON OF ORIGINAL AND SUBSTITUTE

 

While C.S.H.B. 2486 may differ from the original in minor or nonsubstantive ways, the following summarizes the substantial differences between the introduced and committee substitute versions of the bill.

 

The substitute expands the type of information that must be accessible on the website to include information sufficient to determine the percentage of the allowed charges for a covered service that will be paid or reimbursed under the plan or policy. The substitute specifies that the information on the website regarding the amount of payment or reimbursement available for services is for a contracting provider dentist.

 

The substitute does not include a prohibition against a plan or policy deducting the amount of an overpayment of a claim from a payment or reimbursement of another claim unless both claims were for dental services provided to the same patient by the same dentist. The substitute includes instead a prohibition against a plan or policy deducting such an overpayment amount from a payment or reimbursement for a dental care service provided by a dentist who did not receive the overpayment.

 

The substitute defines "predetermination" for purposes of the statutory provision establishing that certain prohibitions do not prohibit the predetermination of benefits for dental care expenses before the attending dentist provides treatment.

 

The substitute does not include a prohibition against a plan or policy that provides a written predetermination of benefits to a dentist that includes a specific benefit payment or reimbursement amount paying or reimbursing the dentist for providing that service to the patient in an amount that is less than the amount set forth in the predetermination, but the substitute includes provisions relating to the prior authorization of dental care services that do the following:

·         define "prior authorization" and exclude from the term a predetermination;

·         require a provider or issuer to provide a dentist, on request of the dentist or a patient, a written prior authorization of benefits for a dental care service for which a prior authorization is required;

·         require the prior authorization to include a specific benefit payment or reimbursement amount; and

·         prohibit a provider or issuer from paying or reimbursing the dentist in an amount that is less than the amount stated in the prior authorization, except under certain specified conditions.