This section requires certain health maintenance organizations to offer a dental point-of-service option in specified employer group situations, and it sets related premium, disclosure, and cost-sharing rules.
Sec. 843.112. DENTAL POINT-OF-SERVICE OPTION. (a) In this section: (1) "Point-of-service option" means a plan provided through a contractual arrangement under which: (A) indemnity benefits for the cost of dental care services, other than emergency care or emergency dental care, are provided by an insurer or group hospital service corporation in conjunction with corresponding benefits arranged or provided by a health maintenance organization; and (B) an enrollee may choose to obtain benefits or services under the indemnity plan or the health maintenance organization plan in accordance with specific provisions of a point-of-service contract. (2) "Provider panel" means the providers with whom a health maintenance organization contracts to provide dental services to enrollees covered under a dental benefit plan. (b) This section applies to a dental health maintenance organization or another single service health maintenance organization that provides dental benefits. This section does not apply to a health maintenance organization that has 10,000 or fewer enrollees in this state who are enrolled in dental benefit plans based on a provider panel. (c) If an employer, association, or other private group arrangement that employs 25 or more employees or has 25 or more members offers and contributes to the cost of dental benefit plan coverage to employees or individuals only through a provider panel, the health maintenance organization with which the employer, association, or other private group arrangement is contracting for the coverage shall offer, or contract with another entity to offer, a dental point-of-service option to the employer, association, or other private group arrangement. The employer may offer the dental point-of-service option to the employee or individual to accept or reject. (d) If a health maintenance organization's dental provider panel is the sole delivery system offered to employees by an employer, the health maintenance organization: (1) shall offer the employer a dental point-of-service option; (2) may not impose a minimum participation level on the dental point-of-service option; and (3) as part of the group enrollment application, shall provide to each employer disclosure statements as required by rules adopted under this code for each dental plan offered. (e) An employer may require an employee or individual who accepts the point-of-service option to be responsible for the payment of a premium, over the amount of the premium for the coverage provided to employees or members under the dental benefit plan offered through a provider panel, directly or by payroll deduction in the same manner in which the other premium is paid. The premium for the point-of-service option must be based on the actuarial value of that coverage. (f) Different cost-sharing provisions may be imposed for the point-of-service option. (g) An employer may charge an employee or individual who accepts the point-of-service option a reasonable administrative fee for costs associated with the employer's reasonable administration of the point-of-service option. Added by Acts 2001, 77th Leg., ch. 1419, Sec. 1, eff. June 1, 2003.