Hughes Dental Bill Bans Down-Coding, Unless The Plan Says So

The text as introduced · 340 words

89R5384 SCR-F

By: Hughes
S.B. No. 1090

A BILL TO BE ENTITLED

AN ACT

relating to bundling and down-coding practices conducted by certain

providers of dental benefits.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:

SECTION 1. Subchapter E, Chapter 1451, Insurance Code, is

amended by adding Section 1451.210 to read as follows:

Sec. 1451.210. LIMITATION ON BUNDLING AND DOWN-CODING. (a)

In this section:

(1) "Bundling" means the practice of combining

distinct medical or dental procedures or components of a more

extensive procedure into one procedure for billing purposes. The

term does not include the denial or adjustment of claims for covered

services in accordance with the patient's dental benefits.

(2) "Down-coding" means the adjustment by a provider

or issuer of an employee benefit plan or health insurance policy of

a submitted claim to reflect a less complex or lower-cost procedure

code. The term does not include the adjustment of payment for

procedures that were improperly or inaccurately billed, or the

denial or adjustment of claims for covered services in accordance

with the patient's dental benefits.

(b) A provider or issuer of an employee benefit plan or

health insurance policy may not change a dentist's submitted

procedure codes through down-coding or bundling unless the provider

or issuer undertakes a professional review of the submitted charges

and supporting clinical information and determines that the

original coding was incorrect, fragmented, or unbundled:

(1) as provided in the current Code on Dental

Procedures and Nomenclature; or

(2) consistent with generally acceptable standards of

care in the practice of dentistry.

SECTION 2. Section 1451.210, Insurance Code, as added by

this Act, applies only to an employee benefit plan for a plan year

that commences on or after January 1, 2026, or a health insurance

policy delivered, issued for delivery, or renewed on or after

January 1, 2026, and any provider network contract entered into on

or after the effective date of this Act in connection with one of

those plans or policies.

SECTION 3. This Act takes effect September 1, 2025.