Bill Text: TX HB2486 | 2019-2020 | 86th Legislature | Enrolled
Bill Title: Relating to certain required disclosures and prohibited practices of certain employee benefit plans and health insurance policies that provide benefits for dental care services.
Spectrum: Moderate Partisan Bill (Republican 9-1)
Status: (Passed) 2019-06-14 - Effective on 9/1/19 [HB2486 Detail]
Download: Texas-2019-HB2486-Enrolled.html
H.B. No. 2486 |
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relating to certain required disclosures and prohibited practices | ||
of certain employee benefit plans and health insurance policies | ||
that provide benefits for dental care services. | ||
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: | ||
SECTION 1. Section 1451.205, Insurance Code, is amended to | ||
read as follows: | ||
Sec. 1451.205. DISCLOSURE OF BENEFIT TERMS. (a) An | ||
employee benefit plan or health insurance policy shall: | ||
(1) if applicable, disclose that the benefit for | ||
dental care services offered is limited to the least costly | ||
treatment; and | ||
(2) specify in dollars and cents the amount of the | ||
payment or reimbursement to be provided for dental care services or | ||
define and explain the standard on which payment of benefits or | ||
reimbursement for the cost of dental care services is based, such | ||
as: | ||
(A) "usual and customary" fees; | ||
(B) "reasonable and customary" fees; | ||
(C) "usual, customary, and reasonable" fees; or | ||
(D) words of similar meaning. | ||
(b) A person or entity who provides or issues an employee | ||
benefit plan or health insurance policy or the employer or employee | ||
organization, if applicable, shall establish an Internet website to | ||
provide resources and information to dentists, insureds, | ||
participants, employees, and members. | ||
(c) An employee benefit plan or health insurance policy | ||
provider or issuer shall make accessible on the Internet website | ||
established under Subsection (b) information about the plan or | ||
policy sufficient for patients and dentists to determine the type | ||
of dental care services covered by the plan or policy, the | ||
percentage of the allowed charges for a covered service that will be | ||
paid or reimbursed under the plan or policy, and, for a contracting | ||
provider dentist, an estimate of the amount of the payment or | ||
reimbursement available for the provider's services under the plan | ||
or policy. Access to the Internet website must be at no charge to | ||
patients under the plan or policy and dentists providing dental | ||
care services to the patients. | ||
(d) An employee benefit plan or health insurance policy | ||
provider or issuer is not required to comply with Subsection (b) or | ||
(c) for a plan or policy that: | ||
(1) provides for payment of the benefit for dental | ||
care services under the plan or policy: | ||
(A) as an indemnity benefit based on a fixed | ||
schedule, regardless of the cost of the dental care service; | ||
(B) on a cash-payment-only basis; | ||
(C) directly to the beneficiary of the plan or | ||
policy or to the beneficiary's assigns; and | ||
(D) regardless of other coverage; and | ||
(2) does not provide for a copayment, a deductible, a | ||
network, or contracting provider dentists. | ||
SECTION 2. Section 1451.206(a), Insurance Code, is amended | ||
to read as follows: | ||
(a) The employee benefit plan or health insurance policy | ||
shall: | ||
(1) provide: | ||
(A) [ |
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noncontracting provider dentist shall be the same as payment or | ||
reimbursement for a contracting provider dentist; [ |
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(B) [ |
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plan or policy may assign the right to payment or reimbursement to | ||
the dentist who provides the dental care services; and | ||
(C) one or more methods of payment or | ||
reimbursement that provide the dentist 100 percent of the | ||
contracted amount of the payment or reimbursement and that do not | ||
require the dentist to incur a fee to access the payment or | ||
reimbursement; and | ||
(2) disclose on the Internet website required under | ||
Section 1451.205 and on request of a dentist or a party to or | ||
beneficiary of the plan or policy the fees, if any, associated with | ||
the methods of payment or reimbursement available under the plan or | ||
policy. | ||
SECTION 3. Sections 1451.207(a) and (c), Insurance Code, | ||
are amended to read as follows: | ||
(a) An employee benefit plan or health insurance policy may | ||
not: | ||
(1) interfere with or prevent an individual who is a | ||
party to or beneficiary of the plan or policy from selecting a | ||
dentist of the individual's choice to provide a dental care service | ||
the plan or policy offers if the dentist selected is licensed in | ||
this state to provide the service; | ||
(2) deny a dentist the right to participate as a | ||
contracting provider under the plan or policy if the dentist is | ||
licensed to provide the dental care services the plan or policy | ||
offers; | ||
(3) authorize a person to regulate, interfere with, or | ||
intervene in the provision of dental care services a dentist | ||
provides a patient, including diagnosis, if the dentist practices | ||
within the scope of the dentist's license; [ |
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(4) require a dentist to make or obtain a dental x-ray | ||
or other diagnostic aid in providing dental care services; or | ||
(5) deduct the amount of an overpayment of a claim from | ||
a payment or reimbursement for a dental care service provided by a | ||
dentist who did not receive the overpayment. | ||
(c) This section does not prohibit the predetermination of | ||
benefits for dental care expenses before the attending dentist | ||
provides treatment. In this subsection, "predetermination" means | ||
an estimate by the patient's employee benefit plan or health | ||
insurance policy provider or issuer of: | ||
(1) the patient's eligibility under the plan or policy | ||
for benefits or covered services; | ||
(2) the amount of the patient's deductible, copayment, | ||
or coinsurance related to benefits or covered services; and | ||
(3) the maximum benefit limits for benefits or covered | ||
services. | ||
SECTION 4. Subchapter E, Chapter 1451, Insurance Code, is | ||
amended by adding Section 1451.208 to read as follows: | ||
Sec. 1451.208. PRIOR AUTHORIZATION OF DENTAL CARE SERVICES. | ||
(a) For purposes of this section, "prior authorization" means a | ||
written and verifiable determination that one or more specific | ||
dental care services are covered under the patient's employee | ||
benefit plan or health insurance policy and are payable and | ||
reimbursable in a specific stated amount, subject to applicable | ||
coinsurance and deductible amounts. The term: | ||
(1) includes preauthorization or similar | ||
authorization; and | ||
(2) does not include a predetermination as defined by | ||
Section 1451.207(c). | ||
(b) For services for which a prior authorization is | ||
required, on request of a patient or treating dentist, an employee | ||
benefit plan or health insurance policy provider or issuer shall | ||
provide to the dentist a written prior authorization of benefits | ||
for a dental care service for the patient. The prior authorization | ||
must include a specific benefit payment or reimbursement amount. | ||
Except as provided by Subsection (c), the plan or policy provider or | ||
issuer may not pay or reimburse the dentist in an amount that is | ||
less than the amount stated in the prior authorization. | ||
(c) An employee benefit plan or health insurance policy | ||
provider or issuer that preauthorizes a dental care service under | ||
Subsection (b) may deny a claim for the dental care service or | ||
reduce payment or reimbursement to the dentist for the service only | ||
if: | ||
(1) the denial or reduction is in accordance with the | ||
patient's employee benefit plan or health insurance policy benefit | ||
limitations, including an annual maximum or frequency of treatment | ||
limitation, and the patient met the benefit limitation after the | ||
date the prior authorization was issued; | ||
(2) the documentation for the claim fails to | ||
reasonably support the claim as preauthorized; | ||
(3) the preauthorized dental care service was not | ||
medically necessary based on the prevailing standard of care on the | ||
date of the service, or is subject to denial under the conditions | ||
for coverage under the patient's plan or policy in effect at the | ||
time the service was preauthorized, because of a change in the | ||
patient's condition or because the patient received additional | ||
dental care services after the date the prior authorization was | ||
issued; | ||
(4) a payor other than the employee benefit plan or | ||
health insurance policy provider or issuer is responsible for | ||
payment of the claim; | ||
(5) the dentist received full payment for the | ||
preauthorized dental care service on which the claim is based; | ||
(6) the claim is fraudulent; | ||
(7) the prior authorization was based wholly or partly | ||
on a material error in information provided to the employee benefit | ||
plan or health insurance policy provider or issuer by any person not | ||
related to the provider or issuer; or | ||
(8) the patient was otherwise ineligible for the | ||
dental care service under the patient's plan or policy, and the plan | ||
or policy provider or issuer did not know and could not reasonably | ||
have known that the patient was ineligible for the dental care | ||
service on the date the plan or policy provider or issuer | ||
preauthorized the dental care service. | ||
SECTION 5. The changes in law made by this Act apply only to | ||
an employee benefit plan or health insurance policy that provides | ||
benefits for dental care services that is delivered, issued for | ||
delivery, renewed, or contracted for on or after the effective date | ||
of this Act. An employee benefit plan or health insurance policy | ||
that provides benefits for dental care services that is delivered, | ||
issued for delivery, renewed, or contracted for before the | ||
effective date of this Act 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 6. This Act takes effect September 1, 2019. | ||
______________________________ | ______________________________ | |
President of the Senate | Speaker of the House | |
I certify that H.B. No. 2486 was passed by the House on April | ||
25, 2019, by the following vote: Yeas 129, Nays 7, 1 present, not | ||
voting; and that the House concurred in Senate amendments to H.B. | ||
No. 2486 on May 24, 2019, by the following vote: Yeas 139, Nays 1, | ||
2 present, not voting. | ||
______________________________ | ||
Chief Clerk of the House | ||
I certify that H.B. No. 2486 was passed by the Senate, with | ||
amendments, on May 22, 2019, by the following vote: Yeas 30, Nays | ||
1. | ||
______________________________ | ||
Secretary of the Senate | ||
APPROVED: __________________ | ||
Date | ||
__________________ | ||
Governor |