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.