88R2204 SCL-F
 
  By: Zaffirini S.B. No. 1981
 
 
 
A BILL TO BE ENTITLED
 
AN ACT
  relating to the relationship between dentists and certain employee
  benefit plans and health insurers.
         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.  Section 1451.2065, Insurance Code, is amended to
  read as follows:
         Sec. 1451.2065.  CONTRACTS WITH DENTISTS.  (a)  In this
  section:
               (1)  "Covered [, "covered] service" means a dental care
  service for which reimbursement is available under a patient's
  employee benefit plan or health insurance policy, or for which
  reimbursement is available subject to a contractual limitation,
  including:
                     (A) [(1)]  a deductible;
                     (B) [(2)]  a copayment;
                     (C) [(3)]  coinsurance;
                     (D) [(4)]  a waiting period;
                     (E) [(5)]  an annual or lifetime maximum limit;
                     (F) [(6)]  a frequency limitation; or
                     (G) [(7)]  an alternative benefit payment.
               (2)  "Insurer" means a provider or issuer of an
  employee benefit plan or health insurance policy.
         (b)  A contract between an insurer and a dentist may not:
               (1)  limit the fee the dentist may charge for a service
  that is not a covered service; or
               (2)  include a provision that:
                     (A)  allows the insurer to deny payment to the
  dentist for a covered service provided to a patient; and
                     (B)  prohibits the dentist from billing for and
  collecting the amount owed for the service from the patient.
         SECTION 3.  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 4.  The changes in law made by this Act apply only to
  an employee benefit plan for a plan year that commences on or after
  January 1, 2024, or a health insurance policy delivered, issued for
  delivery, or renewed on or after January 1, 2024, and any provider
  network contract entered into on or after the effective date of this
  Act in connection with one of those plans or policies.  An employee
  benefit plan for a plan year that commenced before January 1, 2024,
  or a health insurance policy delivered, issued for delivery, or
  renewed before January 1, 2024, and any provider network contract
  entered into before, on, or after the effective date of this Act in
  connection with one of those plans or policies is governed by the
  law as it existed immediately before the effective date of this Act,
  and that law is continued in effect for that purpose.
         SECTION 5.  This Act takes effect September 1, 2023.