|
|
|
A BILL TO BE ENTITLED
|
|
AN ACT
|
|
relating to requirements for overpayment recovery and third party |
|
access to provider networks for certain insurance policies and |
|
benefit plans that provide dental benefits. |
|
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|
SECTION 1. Section 1451.206, Insurance Code, is amended by |
|
adding Subsections (d) and (e) to read as follows: |
|
(d) An employee benefit plan or health insurance policy |
|
provider or issuer may not recover an overpayment made to a dentist |
|
unless: |
|
(1) not later than the 180th day after the date the |
|
dentist receives the payment, the provider or issuer provides |
|
written notice of the overpayment to the dentist that includes the |
|
basis and specific reasons for the request for recovery of funds; |
|
and |
|
(2) the dentist: |
|
(A) fails to provide a written objection to the |
|
request for recovery of funds and does not make arrangements for |
|
repayment of the requested funds on or before the 45th day after the |
|
date the dentist receives the notice; or |
|
(B) objects to the request in accordance with the |
|
procedure described by Subsection (e) and exhausts all rights of |
|
appeal. |
|
(e) An employee benefit plan or health insurance policy |
|
provider or issuer shall provide a dentist with the opportunity to |
|
challenge an overpayment recovery request and establish written |
|
policies and procedures for a dentist to object to an overpayment |
|
recovery request. The procedures must allow the dentist to access |
|
the claims information in dispute. |
|
SECTION 2. Subchapter E, Chapter 1451, Insurance Code, is |
|
amended by adding Section 1451.209 to read as follows: |
|
Sec. 1451.209. REQUIREMENTS FOR THIRD PARTY ACCESS TO |
|
PROVIDER NETWORKS. (a) At the time a provider network contract is |
|
entered into or when material modifications are made to the |
|
contract relevant to granting a third party access to the contract, |
|
an employee benefit plan or health insurance policy provider or |
|
issuer shall allow any dentist that is part of the provider network |
|
to elect not to participate in the third party access to the |
|
contract and to elect not to enter into a contract directly with the |
|
third party that will obtain access to the provider network. This |
|
subsection does not permit the plan or policy provider or issuer to |
|
cancel or otherwise end a contractual relationship with a dentist |
|
if the dentist elects to not participate in or agree to third party |
|
access to the provider network contract. |
|
(b) An employee benefit plan or health insurance policy |
|
provider or issuer that enters into a provider network contract |
|
with a dentist, or a contracting entity that has leased or acquired |
|
the provider network contract, may grant a third party access to the |
|
provider network contract or to a dentist's dental care services or |
|
contractual discounts provided under the contract only if: |
|
(1) the provider network contract or each employee |
|
benefit plan or health insurance policy for which the provider |
|
network contract was entered into, leased, or acquired |
|
conspicuously states that the provider or issuer or contracting |
|
entity may enter into an agreement with a third party that allows |
|
the third party to obtain the provider's, issuer's, or contracting |
|
entity's rights and responsibilities as if the third party were the |
|
provider, issuer, or contracting entity; |
|
(2) if the contracting entity is an employee benefit |
|
plan or health insurance policy provider or issuer, the entity's |
|
plan or policy for which the provider network contract is leased or |
|
acquired conspicuously states, in addition to the language required |
|
by Subdivision (1), that the dentist may elect not to participate in |
|
third party access to the provider network contract: |
|
(A) at the time the provider network contract is |
|
entered into; or |
|
(B) when there are material modifications to the |
|
provider network contract relevant to granting a third party access |
|
to the provider network contract; |
|
(3) the third party accessing the provider network |
|
contract agrees to comply with all of the original contract's |
|
terms, including the contracted fee schedule and obligations |
|
concerning patient steerage; |
|
(4) the provider, issuer, or other contracting entity |
|
provides in writing to the dentist the names of all third parties |
|
with access to the provider network in existence as of the date the |
|
contract is entered into; |
|
(5) the provider, issuer, or other contracting entity |
|
identifies all current third parties with access to the provider |
|
network on its Internet website with a list updated at least once |
|
every 90 days; |
|
(6) the provider, issuer, or other contracting entity |
|
requires a third party with access to the provider network to |
|
identify the source of any discount on all remittance advices or |
|
explanations of payment under which a discount is taken, provided |
|
that this subsection does not apply to electronic transactions |
|
mandated by the Health Insurance Portability and Accountability Act |
|
of 1996 (Pub. L. No. 104-191); |
|
(7) the provider, issuer, or other contracting entity |
|
provides written or electronic notice to network dentists that a |
|
third party will lease, acquire, or obtain access to the provider |
|
network at least 30 days before the lease or access takes effect; |
|
(8) the provider, issuer, or other contracting entity |
|
provides written or electronic notice to network dentists of the |
|
termination of the provider network contract at least 30 days |
|
before the termination date; |
|
(9) a third party's right to a dentist's discounted |
|
rate ceases as of the termination date of the provider network |
|
contract; and |
|
(10) the provider, issuer, or other contracting entity |
|
makes available a copy of the provider network contract relied on in |
|
the adjudication of a claim to a network dentist not later than the |
|
30th day after the date the dentist requests a copy of that |
|
contract. |
|
(c) Subsections (b)(7) and (8) do not apply to a contracting |
|
entity that only organizes and leases networks but does not engage |
|
in the business of insurance. |
|
(d) A person may not bind or require a dentist to perform |
|
dental care services under a provider network contract that has |
|
been sold, leased, or assigned to a third party or for which a third |
|
party has otherwise obtained provider network access in violation |
|
of this section. |
|
(e) This section does not apply: |
|
(1) if access to a provider network contract is |
|
granted to: |
|
(A) a third party operating in accordance with |
|
the same brand licensee program as the employee benefit plan |
|
provider, health insurance policy issuer, or other contracting |
|
entity selling or leasing the provider network contract, provided |
|
that the third party accessing the provider network contract agrees |
|
to comply with all of the original contract's terms, including the |
|
contracted fee schedule and obligations concerning patient |
|
steerage; or |
|
(B) an entity that is an affiliate of the |
|
employee benefit plan provider, health insurance policy issuer, or |
|
other contracting entity selling or leasing the provider network |
|
contract, provided that: |
|
(i) the provider, issuer, or entity |
|
publicly discloses the names of the affiliates on its Internet |
|
website; and |
|
(ii) the affiliate accessing the provider |
|
network contract agrees to comply with all of the original |
|
contract's terms, including the contracted fee schedule and |
|
obligations concerning patient steerage; |
|
(2) to the child health plan program under Chapter 62, |
|
Health and Safety Code, or the health benefits plan for children |
|
under Chapter 63, Health and Safety Code; or |
|
(3) to a Medicaid managed care program operated under |
|
Chapter 533, Government Code, or a Medicaid program operated under |
|
Chapter 32, Human Resources Code. |
|
SECTION 3. Sections 1451.206(d) and (e) and 1451.209, |
|
Insurance Code, as added by this Act, apply only to an employee |
|
benefit plan for a plan year that commences on or after January 1, |
|
2022, or a health insurance policy delivered, issued for delivery, |
|
or renewed on or after January 1, 2022, and any provider network |
|
contract entered into on or after the effective date of this Act in |
|
connection with one of those plans and policies. |
|
SECTION 4. This Act takes effect September 1, 2021. |