SECTION 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.

Source Note: The provisions of this §21.3604 adopted to be effective June 13, 2004, 29 TexReg 5637