28 TAC §§21.3601-21.3606
The Texas Department of Insurance proposes new §§21.3601 - 21.3606 concerning dental care benefits in health insurance policies. The proposed rules are necessary to clarify Article 21.53 and the allowable standards for the payment of benefits or reimbursement for the cost of dental care services provided by contracting and non-contracting dentists. The department is aware that some insurers are contracting with dentists for reduced fees when providing dental care services to insureds. This practice has caused confusion regarding the requirement that health insurance policies pay or reimburse non-contracting dentists using the same standard as contracting dentists. The proposed rules clarify that a payment or reimbursement standard expressed as a percentage of a contracting or non-contacting dentist´s charges is acceptable if it is uniformly applied to contracting and non-contracting dentists. Proposed §21.3601 outlines the scope of the rules. Proposed §21.3602 defines terms relating to dental care benefits. Proposed §21.3603 states that a health insurance policy may not prevent an insured from selecting the dentist of his choice or interfere with the diagnosis or treatment of a dentist practicing within the scope of the dentist´s license. Proposed §21.3604 prohibits a health insurance policy from containing a different level of payment of benefits for covered dental care services based on whether the services were provided by a contracting or non-contracting dentist. The proposed section makes clear that the payment or reimbursement percentage must not vary based on whether the services were performed by a contracting or non-contracting dentist. This results in a single standard for payment to all dentists under the health insurance policy. The proposed section clarifies that the payment or reimbursement standard may be expressed as a percentage of a dentist´s charges and that the charges may be defined as both a contracted rate and a usual and customary rate. Th is may result in different monetary amounts being paid to dentists depending on whether the dentist contracts with the insurer. In such a circumstance, the differing amounts are based on the amount charged by the dentists and not on the payment or reimbursement standard included in the policy. The proposed section also states that an insurer is not required to make payment to a non-contracting dentist that is greater than the amount charged for the service. Proposed §21.3605 states that the requirements of the rules are applicable to health insurance polices containing benefits for dental care services issued or renewed on or after May 1, 2004. The proposal does not require insurers to make any changes to existing policies upon renewal if the policies were otherwise in compliance with Article 21.53. Proposed §21.3606 contains a severability clause indicating that if any provision in the rules is found to be invalid, those provisions that can otherwise be given effect will not be affected.
Kim Stokes, Senior Associate Commissioner of Life, Health & Licensing has determined that for each year of the first five years the proposed sections will be in effect, there will be no fiscal impact to state and local governments as a result of the enforcement or administration of the rule. There will be no measurable effect on local employment or the local economy as a result of the proposal.
Ms. Stokes has determined that for each year of the first five years the sections are in effect, the public benefits anticipated as a result of the proposed sections will be increased clarity in the dental insurance market concerning the allowable payment or reimbursement standards in a health insurance policy containing benefits for dental care services. Any economic cost to persons required to comply with the proposed sections results from the provisions of Insurance Code Article 21.53, and not as a result of the adoption, enforcement or administration of the proposed sections. The proposed sections clarify allowable payment standards and do not impose any additional requirements on insurers. Policies containing benefits for dental care services previously approved by the department and in compliance with Article 21.53 will not be affected by the proposed sections. There is no disproportionate economic impact on small and micro businesses. Even if the proposed sections would have an adverse economic effect on small or micro businesses, it is neither legal nor feasible to waive the provisions of the proposed rules for small and micro businesses because the Insurance Code requires equal application of these provisions to all affected individuals.
To be considered, written comments on the proposal must be submitted no later than 5:00 p.m.on April 12, 2004 to Gene C. Jarmon, General Counsel and Chief Clerk, Mail Code 113-2A, Texas Department of Insurance, P. O. Box 149104, Austin, Texas 78714-9104. An additional copy of the comment must be simultaneously submitted to Kim Stokes, Senior Associate Commissioner, Life, Health & Licensing, Mail Code 107-2A, Texas Department of Insurance, P.O. Box 149104, Austin, Texas 78714-9104. A request for a public hearing should be submitted separately to the Office of the Chief Clerk.
The new sections are proposed under the Insurance Code Article 21.53 and §36.001. Article 21.53 provides requirements for health insurance polices containing benefits for dental care services, including requirements relating to an insured´s right to choose a dentist and payment or reimbursement standards as applied to both contracting and non-contracting dentists. Section 36.001 provides that the Commissioner of Insurance may adopt any rules necessary and appropriate to implement the powers and duties of the Texas Department of Insurance under the Insurance Code and other laws of this state.
The following article is affected by this proposal: Texas Insurance Code Article 21.53
§21.3601. Scope. This subchapter applies to insurers who issue health insurance policies covering dental care services.
§21.3602. Definitions. The following words and terms, when used in this subchapter, shall have the following meanings unless the context clearly indicates otherwise:
(1) Contracting dentist A dentist who, as a contracting provider under a health insurance policy, has entered into a written agreement with an insurer to limit charges for dental care services provided to insureds.
(2) Dental care services Any services furnished to a person for the purpose of preventing, alleviating, curing, or healing human dental illness or injury.
(3) Dentist Any person who furnishes dental care services and who is licensed as a dentist by the State of Texas.
(4) Health insurance policy An individual, group, blanket, or franchise insurance policy or certificate or insurance agreement or rider that is delivered, renewed or issued for delivery in this state and that provides benefits for dental care services.
(5) Insurer An insurance company that is authorized under the Texas Insurance Code to issue, deliver or issue for delivery in this state health insurance policies or certificates.
(6) Non-contracting dentist A dentist who is not a contracting dentist as defined in this section.
§21.3603. Right to Choose Dentist. A health insurance policy providing benefits for dental care services shall not:
(1) prevent an insured from selecting the dentist of his choice to furnish dental care services offered by the policy or interfere with the selection of any dentist, provided the dental care services are within the scope of the dentist´s license; or
(2) authorize any person to regulate, interfere, or intervene in any manner in the diagnosis or treatment rendered by a dentist to a patient for the purpose of providing dental care services, provided the dentist practices within the scope of the dentist´s license.
§21.3604. Payment of Benefits for Dental Care Services.
(a) A health insurance policy shall not provide a different level of payment of benefits or reimbursement, including deductibles or other cost-sharing provisions, for covered dental care services based on whether the services are provided by a contracting or non-contracting dentist.
(b) A health insurance policy shall define and explain the standard of payment or reimbursement for dental care services. In defining the standard, a policy may express the level of payment or reimbursement as a percentage of charges for dental care services, provided the insurer uses the same percentage for both contracting and non-contracting dentists.
(c) A health insurance policy may, in the same policy, apply the percentage specified in subsection (b) of this section to a contracted rate and a fee expressed as "usual and customary" or words of similar import.
(d) Notwithstanding subsection (a) of this section, an insurer is not required to make payment to a non-contracting dentist that is greater than the actual fee charged for the dental care service.
(e) A health insurance policy must disclose, if applicable, that the benefit offered is limited to the least costly treatment.
(f) A health insurance policy must provide that an insured may assign the right to benefits to a dentist who provides dental care services, in which case, the insurer shall pay benefits directly to the designated dentist, and such payment shall discharge the insurer´s obligation to pay those benefits.
§21.3605. Applicability. This subchapter is applicable to health insurance policies issued or renewed on or after May 1, 2004.
§21.3606. Severability. If any provision of this subchapter or the application thereof to any person or circumstances is for any reason held invalid, the invalidity shall not affect the other provisions or any application of this subchapter that can be given effect without the invalid provisions or application. To this end all provisions of this subchapter are declared severable.