28 Tex. Admin. Code § 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, maximums 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.
Notes
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