Texas Administrative Code
Title 28 - INSURANCE
Part 1 - TEXAS DEPARTMENT OF INSURANCE
Chapter 21 - TRADE PRACTICES
Subchapter BB - DENTAL CARE BENEFITS
Section 21.3604 - Payment of Benefits for Dental Care Services

Universal Citation: 28 TX Admin Code § 21.3604

Current through Reg. 50, No. 13; March 28, 2025

(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.

Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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