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A BILL TO BE ENTITLED
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AN ACT
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relating to certain required disclosures and prohibited practices |
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of certain employee benefit plans and health insurance policies |
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that provide benefits for dental care services. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Section 1451.205, Insurance Code, is amended to |
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read as follows: |
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Sec. 1451.205. DISCLOSURE OF BENEFIT TERMS. (a) An |
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employee benefit plan or health insurance policy shall: |
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(1) if applicable, disclose that the benefit for |
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dental care services offered is limited to the least costly |
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treatment; and |
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(2) specify in dollars and cents the amount of the |
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payment or reimbursement to be provided for dental care services or |
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define and explain the standard on which payment of benefits or |
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reimbursement for the cost of dental care services is based, such |
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as: |
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(A) "usual and customary" fees; |
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(B) "reasonable and customary" fees; |
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(C) "usual, customary, and reasonable" fees; or |
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(D) words of similar meaning. |
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(b) A person or entity who provides or issues an employee |
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benefit plan or health insurance policy or the employer or employee |
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organization, if applicable, shall establish an Internet website to |
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provide resources and information to dentists, insureds, |
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participants, employees, and members. |
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(c) An employee benefit plan or health insurance policy |
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provider or issuer shall make accessible on the Internet website |
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established under Subsection (b) information about the plan or |
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policy sufficient for patients and dentists to determine the type |
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of dental care services covered by the plan or policy, the |
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percentage of the allowed charges for a covered service that will be |
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paid or reimbursed under the plan or policy, and, for a contracting |
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provider dentist, an estimate of the amount of the payment or |
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reimbursement available for the provider's services under the plan |
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or policy. Access to the Internet website must be at no charge to |
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patients under the plan or policy and dentists providing dental |
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care services to the patients. |
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SECTION 2. Section 1451.206(a), Insurance Code, is amended |
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to read as follows: |
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(a) The employee benefit plan or health insurance policy |
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shall: |
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(1) provide: |
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(A) [(1)] that payment or reimbursement for a |
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noncontracting provider dentist shall be the same as payment or |
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reimbursement for a contracting provider dentist; [and] |
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(B) [(2)] that the party to or beneficiary of the |
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plan or policy may assign the right to payment or reimbursement to |
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the dentist who provides the dental care services; and |
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(C) one or more methods of payment or |
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reimbursement that provide the dentist 100 percent of the |
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contracted amount of the payment or reimbursement and that do not |
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require the dentist to incur a fee to access the payment or |
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reimbursement; and |
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(2) disclose on the Internet website required under |
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Section 1451.205 and on request of a dentist or a party to or |
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beneficiary of the plan or policy the fees, if any, associated with |
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the methods of payment or reimbursement available under the plan or |
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policy. |
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SECTION 3. Sections 1451.207(a) and (c), Insurance Code, |
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are amended to read as follows: |
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(a) An employee benefit plan or health insurance policy may |
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not: |
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(1) interfere with or prevent an individual who is a |
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party to or beneficiary of the plan or policy from selecting a |
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dentist of the individual's choice to provide a dental care service |
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the plan or policy offers if the dentist selected is licensed in |
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this state to provide the service; |
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(2) deny a dentist the right to participate as a |
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contracting provider under the plan or policy if the dentist is |
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licensed to provide the dental care services the plan or policy |
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offers; |
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(3) authorize a person to regulate, interfere with, or |
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intervene in the provision of dental care services a dentist |
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provides a patient, including diagnosis, if the dentist practices |
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within the scope of the dentist's license; [or] |
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(4) require a dentist to make or obtain a dental x-ray |
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or other diagnostic aid in providing dental care services; or |
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(5) deduct the amount of an overpayment of a claim from |
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a payment or reimbursement for a dental care service provided by a |
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dentist who did not receive the overpayment. |
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(c) This section does not prohibit the predetermination of |
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benefits for dental care expenses before the attending dentist |
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provides treatment. In this subsection, "predetermination" means |
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an estimate by the patient's employee benefit plan or health |
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insurance policy provider or issuer of: |
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(1) the patient's eligibility under the plan or policy |
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for benefits or covered services; |
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(2) the amount of the patient's deductible, copayment, |
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or coinsurance related to benefits or covered services; and |
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(3) the maximum benefit limits for benefits or covered |
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services. |
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SECTION 4. Subchapter E, Chapter 1451, Insurance Code, is |
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amended by adding Section 1451.208 to read as follows: |
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Sec. 1451.208. PRIOR AUTHORIZATION OF DENTAL CARE SERVICES. |
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(a) For purposes of this section, "prior authorization" means a |
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written and verifiable determination that one or more specific |
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dental care services are covered under the patient's employee |
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benefit plan or health insurance policy and are payable and |
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reimbursable in a specific stated amount, subject to applicable |
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coinsurance and deductible amounts. The term: |
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(1) includes preauthorization or similar |
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authorization; and |
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(2) does not include a predetermination as defined by |
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Section 1451.207(c). |
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(b) For services for which a prior authorization is |
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required, on request of a patient or treating dentist, an employee |
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benefit plan or health insurance policy provider or issuer shall |
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provide to the dentist a written prior authorization of benefits |
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for a dental care service for the patient. The prior authorization |
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must include a specific benefit payment or reimbursement amount. |
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Except as provided by Subsection (c), the plan or policy provider or |
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issuer may not pay or reimburse the dentist in an amount that is |
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less than the amount stated in the prior authorization. |
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(c) An employee benefit plan or health insurance policy |
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provider or issuer that preauthorizes a dental care service under |
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Subsection (b) may deny a claim for the dental care service or |
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reduce payment or reimbursement to the dentist for the service only |
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if: |
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(1) the denial or reduction is in accordance with the |
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patient's employee benefit plan or health insurance policy benefit |
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limitations, including an annual maximum or frequency of treatment |
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limitation, and the patient met the benefit limitation after the |
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date the prior authorization was issued; |
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(2) the documentation for the claim fails to |
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reasonably support the claim as preauthorized; |
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(3) the preauthorized dental care service was not |
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medically necessary based on the prevailing standard of care on the |
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date of the service, or is subject to denial under the conditions |
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for coverage under the patient's plan or policy in effect at the |
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time the service was preauthorized, because of a change in the |
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patient's condition or because the patient received additional |
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dental care services after the date the prior authorization was |
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issued; |
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(4) a payor other than the employee benefit plan or |
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health insurance policy provider or issuer is responsible for |
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payment of the claim; |
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(5) the dentist received full payment for the |
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preauthorized dental care service on which the claim is based; |
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(6) the claim is fraudulent; |
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(7) the prior authorization was based wholly or partly |
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on a material error in information provided to the employee benefit |
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plan or health insurance policy provider or issuer by any person not |
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related to the provider or issuer; or |
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(8) the patient was otherwise ineligible for the |
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dental care service under the patient's plan or policy, and the plan |
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or policy provider or issuer did not know and could not reasonably |
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have known that the patient was ineligible for the dental care |
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service on the date the plan or policy provider or issuer |
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preauthorized the dental care service. |
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SECTION 5. The changes in law made by this Act apply only to |
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an employee benefit plan or health insurance policy that provides |
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benefits for dental care services that is delivered, issued for |
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delivery, renewed, or contracted for on or after the effective date |
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of this Act. An employee benefit plan or health insurance policy |
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that provides benefits for dental care services that is delivered, |
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issued for delivery, renewed, or contracted for before the |
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effective date of this Act is governed by the law as it existed |
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immediately before the effective date of this Act, and that law is |
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continued in effect for that purpose. |
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SECTION 6. This Act takes effect September 1, 2019. |