| 1 | 1 | | 89R5384 SCR-F |
|---|
| 2 | 2 | | By: Hughes S.B. No. 1090 |
|---|
| 3 | 3 | | |
|---|
| 4 | 4 | | |
|---|
| 5 | 5 | | |
|---|
| 6 | 6 | | |
|---|
| 7 | 7 | | A BILL TO BE ENTITLED |
|---|
| 8 | 8 | | AN ACT |
|---|
| 9 | 9 | | relating to bundling and down-coding practices conducted by certain |
|---|
| 10 | 10 | | providers of dental benefits. |
|---|
| 11 | 11 | | BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: |
|---|
| 12 | 12 | | SECTION 1. Subchapter E, Chapter 1451, Insurance Code, is |
|---|
| 13 | 13 | | amended by adding Section 1451.210 to read as follows: |
|---|
| 14 | 14 | | Sec. 1451.210. LIMITATION ON BUNDLING AND DOWN-CODING. (a) |
|---|
| 15 | 15 | | In this section: |
|---|
| 16 | 16 | | (1) "Bundling" means the practice of combining |
|---|
| 17 | 17 | | distinct medical or dental procedures or components of a more |
|---|
| 18 | 18 | | extensive procedure into one procedure for billing purposes. The |
|---|
| 19 | 19 | | term does not include the denial or adjustment of claims for covered |
|---|
| 20 | 20 | | services in accordance with the patient's dental benefits. |
|---|
| 21 | 21 | | (2) "Down-coding" means the adjustment by a provider |
|---|
| 22 | 22 | | or issuer of an employee benefit plan or health insurance policy of |
|---|
| 23 | 23 | | a submitted claim to reflect a less complex or lower-cost procedure |
|---|
| 24 | 24 | | code. The term does not include the adjustment of payment for |
|---|
| 25 | 25 | | procedures that were improperly or inaccurately billed, or the |
|---|
| 26 | 26 | | denial or adjustment of claims for covered services in accordance |
|---|
| 27 | 27 | | with the patient's dental benefits. |
|---|
| 28 | 28 | | (b) A provider or issuer of an employee benefit plan or |
|---|
| 29 | 29 | | health insurance policy may not change a dentist's submitted |
|---|
| 30 | 30 | | procedure codes through down-coding or bundling unless the provider |
|---|
| 31 | 31 | | or issuer undertakes a professional review of the submitted charges |
|---|
| 32 | 32 | | and supporting clinical information and determines that the |
|---|
| 33 | 33 | | original coding was incorrect, fragmented, or unbundled: |
|---|
| 34 | 34 | | (1) as provided in the current Code on Dental |
|---|
| 35 | 35 | | Procedures and Nomenclature; or |
|---|
| 36 | 36 | | (2) consistent with generally acceptable standards of |
|---|
| 37 | 37 | | care in the practice of dentistry. |
|---|
| 38 | 38 | | SECTION 2. Section 1451.210, Insurance Code, as added by |
|---|
| 39 | 39 | | this Act, applies only to an employee benefit plan for a plan year |
|---|
| 40 | 40 | | that commences on or after January 1, 2026, or a health insurance |
|---|
| 41 | 41 | | policy delivered, issued for delivery, or renewed on or after |
|---|
| 42 | 42 | | January 1, 2026, and any provider network contract entered into on |
|---|
| 43 | 43 | | or after the effective date of this Act in connection with one of |
|---|
| 44 | 44 | | those plans or policies. |
|---|
| 45 | 45 | | SECTION 3. This Act takes effect September 1, 2025. |
|---|