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A BILL TO BE ENTITLED
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AN ACT
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relating to bundling and down-coding practices conducted by certain |
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providers of dental benefits. |
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BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
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SECTION 1. Subchapter E, Chapter 1451, Insurance Code, is |
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amended by adding Section 1451.210 to read as follows: |
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Sec. 1451.210. LIMITATION ON BUNDLING AND DOWN-CODING. (a) |
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In this section: |
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(1) "Bundling" means the practice of combining |
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distinct medical or dental procedures or components of a more |
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extensive procedure into one procedure for billing purposes. The |
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term does not include the denial or adjustment of claims for covered |
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services in accordance with the patient's dental benefits. |
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(2) "Down-coding" means the adjustment by a provider |
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or issuer of an employee benefit plan or health insurance policy of |
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a submitted claim to reflect a less complex or lower-cost procedure |
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code. The term does not include the adjustment of payment for |
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procedures that were improperly or inaccurately billed, or the |
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denial or adjustment of claims for covered services in accordance |
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with the patient's dental benefits. |
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(b) A provider or issuer of an employee benefit plan or |
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health insurance policy may not change a dentist's submitted |
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procedure codes through down-coding or bundling unless the provider |
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or issuer undertakes a professional review of the submitted charges |
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and supporting clinical information and determines that the |
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original coding was incorrect, fragmented, or unbundled: |
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(1) as provided in the current Code on Dental |
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Procedures and Nomenclature; or |
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(2) consistent with generally acceptable standards of |
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care in the practice of dentistry. |
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SECTION 2. Section 1451.210, Insurance Code, as added by |
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this Act, applies only to an employee benefit plan for a plan year |
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that commences on or after January 1, 2026, or a health insurance |
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policy delivered, issued for delivery, or renewed on or after |
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January 1, 2026, and any provider network contract entered into on |
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or after the effective date of this Act in connection with one of |
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those plans or policies. |
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SECTION 3. This Act takes effect September 1, 2025. |