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. This 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 and 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 rules. 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 and 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.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State on March 1, 2004.
TRD-200401660
Gene C. Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: April 11, 2004
For further information, please call: (512) 463-6327