88R19703 SCL-F
By: Oliverson, et al. H.B. No. 1527
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 both:
(A) allows the insurer to disallow a service,
resulting in denial of payment to the dentist for a service that
ordinarily would have been covered; and
(B) prohibits the dentist from billing for and
collecting the amount owed from the patient for that service if
there is a dental necessity, as defined by Section 32.054, Human
Resources Code, for that service.
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.