§ 1451.205 — DISCLOSURE OF BENEFIT TERMS.

Texas § 1451.205

• Jurisdiction: Texas
• Code IN: Insurance Code

Text

Sec. 1451.205. DISCLOSURE OF BENEFIT TERMS. (a) An employee benefit plan or health insurance policy shall:
(1) if applicable, disclose that the benefit for dental care services offered is limited to the least costly treatment; and
(2) specify in dollars and cents the amount of the payment or reimbursement to be provided for dental care services or define and explain the standard on which payment of benefits or reimbursement for the cost of dental care services is based, such as:
(A) "usual and customary" fees;
(B) "reasonable and customary" fees;
(C) "usual, customary, and reasonable" fees; or
(D) words of similar meaning.
(b) A person or entity who provides or issues an employee benefit plan or health insurance policy or the employer or employee organization, if applicable, shall establish an Internet website to provide resources and information to dentists, insureds, participants, employees, and members.
(c) An employee benefit plan or health insurance policy provider or issuer shall make accessible on the Internet website established under Subsection (b) information about the plan or policy sufficient for patients and dentists to determine the type of dental care services covered by the plan or policy, the percentage of the allowed charges for a covered service that will be paid or reimbursed under the plan or policy, and, for a contracting provider dentist, an estimate of the amount of the payment or reimbursement available for the provider's services under the plan or policy. Access to the Internet website must be at no charge to patients under the plan or policy and dentists providing dental care services to the patients.
(d) An employee benefit plan or health insurance policy provider or issuer is not required to comply with Subsection (b) or (c) for a plan or policy that:
(1) provides for payment of the benefit for dental care services under the plan or policy:
(A) as an indemnity benefit based on a fixed schedule, regardless of the cost of the dental care service;
(B) on a cash-payment-only basis;
(C) directly to the beneficiary of the plan or policy or to the beneficiary's assigns; and
(D) regardless of other coverage; and
(2) does not provide for a copayment, a deductible, a network, or contracting provider dentists.

Legislative History

Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1, 2005. Amended by: Acts 2019, 86th Leg., R.S., Ch. 1290 (H.B. 2486 ), Sec. 1, eff. September 1, 2019.