87R5838 MWC-F

By: Oliverson H.B. No. 1934

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 90th 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 establish written policies and procedures for a dentist to object to an overpayment recovery request and provide a copy of the policies and procedures to the dentist with each 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, sold, leased, or renewed 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. The provider or issuer may not require that a dentist terminate or modify the dentist's preexisting contractual relationship with the provider or issuer based on the dentist's election to not participate in or agree to third party access to the contract network.

(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 at the time the provider network contract is entered into, sold, leased, or renewed or 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, sold, leased, or renewed;

(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 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, acquisition, or access takes effect;

(8) the provider, issuer, or other contracting entity provides written 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) 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.

(d) 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; 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 the provider, issuer, or entity publicly discloses the names of the affiliates on its Internet website;

(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 or renewed 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.