CHAPTER 43. ORAL HEALTH IMPROVEMENT - Texas Statutes

HEALTH AND SAFETY CODE

TITLE 2. HEALTH

SUBTITLE B. TEXAS DEPARTMENT OF HEALTH PROGRAMS

CHAPTER 43. ORAL HEALTH IMPROVEMENT

Sec. 43.001. SHORT TITLE. This chapter may be cited as the

Texas Oral Health Improvement Act.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.002. LIBERAL CONSTRUCTION. It is the intent of the

legislature that this chapter be construed liberally so that

eligible individuals may receive appropriate and adequate oral

health services in a timely manner.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.003. DEFINITIONS. (a) In this chapter:

(1) "Dentist" means an individual licensed by the State Board of

Dental Examiners to practice dentistry in this state.

(2) "Oral health services" means:

(A) preventive or treatment services affecting the structures of

the mouth, including the hard and soft tissues such as teeth,

jaws, gums, vestibule, tongue, cheeks, lips, floor and roof of

the mouth, and adjacent masticatory structures; and

(B) oral health education and promotion activities.

(3) "Other benefit" means a benefit, other than a benefit

provided under this chapter, to which an individual is entitled

for the payment of the costs of oral health treatment services,

including benefits available from:

(A) an insurance policy, group oral health plan, or prepaid oral

care plan;

(B) Title XVIII or Title XIX of the Social Security Act, as

amended (42 U.S.C. Sec. 1395 et seq. and 42 U.S.C. Sec. 1396 et

seq.);

(C) the Veterans Administration;

(D) the Civilian Health and Medical Program of the Uniformed

Services;

(E) workers' compensation or any other compulsory employer's

insurance program;

(F) a public program created by federal law, state law, or the

ordinances or rules of a municipality or other political

subdivision of the state; or

(G) a cause of action for the expenses of dental or oral health

treatment services, or a settlement or judgment based on the

cause of action, if the expenses are related to the need for

treatment services provided under this chapter.

(4) "Provider" means a person who, through a contract with the

department, furnishes oral health treatment services that are

purchased by the department for the purposes of this chapter.

(5) "Support" means to contribute money or services necessary

for a person's maintenance, including food, clothing, shelter,

transportation, and health care.

(b) The board by rule may define a word or term not defined by

Subsection (a) as necessary to administer this chapter. The board

may not define a word or term so that the word or term is

inconsistent or in conflict with the purposes of this chapter.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.004. ORAL HEALTH IMPROVEMENT SERVICES PROGRAM. (a) The

oral health improvement services program is in the department to

provide comprehensive oral health services to eligible

individuals.

(b) The board shall adopt rules to govern the program, to

prescribe the type, amount, and duration of oral health services

to be provided, and, if necessary to conform to budgetary

limitations, to prescribe a system of program priorities

regarding the types of services to be furnished, the geographic

areas to be covered, or the classes of individuals eligible for

services.

(c) Except as limited by Subsection (b), the department shall

develop an integrated framework for the equitable provision of

oral health services throughout the state or designated

geographic areas, using existing public and private health care

resources when possible.

(d) The program may consist of all or any combination of the

following:

(1) treatment services for eligible individuals, including:

(A) emergency care for relief of pain and infection, including

extractions and basic restorative services to prevent premature

loss of teeth;

(B) periodontal therapy for the prevention and treatment of

periodontal disease;

(C) endodontics to maintain aesthetics and occlusion;

(D) orthodontic care only in cases of severely handicapping

malocclusion; and

(E) oral surgery and prosthetics in cases in which health is

impaired;

(2) a program of oral disease prevention, including:

(A) the fluoridation of community water supplies;

(B) fluoride mouth rinse programs in schools;

(C) the promotion and implementation of sealants programs; and

(D) the development of appropriate means for prevention of oral

disease, including the continued use of recognized methods of

primary, secondary, and tertiary prevention;

(3) oral health education and promotion, including:

(A) public health education to promote the prevention of oral

disease through self-help methods, including the initiation and

expansion of preschool, school age, and adult education programs;

(B) organized continuing health education training programs for

health care providers; and

(C) preventive health education information for the public; and

(4) facilitation of access to oral health services, including:

(A) the improvement of the existing oral health services

delivery system for the provision of services to low-income

residents;

(B) outreach activities to inform the public of the type and

availability of oral health services to increase the

accessibility of oral health care for low-income residents; and

(C) assistance and cooperation in promoting better distribution

of dentists and other oral health professionals throughout the

state.

(e) The department may provide services only as prescribed by

board rules.

(f) The services listed in Subsection (d) may be furnished

either directly by the department or through a network of

approved providers.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.005. ADMINISTRATION. (a) The department shall:

(1) administer the program of oral health services established

by the board; and

(2) adopt the design and content of all forms necessary for the

program.

(b) The department may conduct field research, collect data, and

prepare statistical and other reports relating to the need for

and the availability of oral health services.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.006. SERVICE PROVIDERS. (a) The board may adopt

substantive and procedural rules relating to:

(1) the selection of dentists, physicians, facilities, and other

providers to furnish program services, including criteria for the

emergency selection of providers; and

(2) the denial, modification, suspension, or termination of a

provider's program participation.

(b) The department shall approve providers to participate in the

program according to the criteria, rules, and procedures adopted

by the board.

(c) The department may pay only for program services furnished

by approved providers, except in an emergency.

(d) The board shall provide a due process hearing procedure for

the resolution of conflicts between the department and a

provider. Chapter 2001, Government Code, do not apply to conflict

resolution procedures adopted under this section.

(e) The department shall render the final administrative

decision in a due process hearing to modify, suspend, or

terminate the approval of a provider.

(f) The department may not terminate a contract while a due

process hearing is pending under this section. The department may

withhold payments while the hearing is pending, but shall pay the

withheld payments and resume contract payments if the final

determination is favorable to the provider.

(g) Subsections (d)-(f) do not apply if a contract:

(1) is canceled by the department because of the exhaustion of

funds;

(2) expires according to its terms; or

(3) is canceled because program services are restricted to

conform to budgetary limitations as prescribed by Section

43.004(b).

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(66), eff.

Sept. 1, 1995.

Sec. 43.007. INDIVIDUAL REFERRAL AND APPLICATION FOR SERVICES.

(a) The board may adopt substantive and procedural rules to

govern the application for admission to the program and the

receipt of treatment services, including the dental, financial,

and other criteria for eligibility to receive treatment services.

(b) An applicant for treatment services must be referred to the

program by a person who knows the individual's economic

condition, such as a school administrator or school nurse, social

worker, municipal or county official, dentist, physician, public

health clinic, community health center, hospital, or any other

source acceptable to the board.

(c) An applicant for treatment services must complete or cause

to be completed an application form prescribed by the department.

(d) The application form must include or be accompanied by:

(1) a statement by the individual, or by the person with a legal

obligation to support the individual, that the individual or the

person is financially unable to pay for all or part of the cost

of the necessary treatment services;

(2) a statement from the referring person that the treatment

services are necessary to prevent or reduce the probability of

pain, infection, or disease; and

(3) any other assurances from the applicant or any other

documentary evidence required by the board to support the

applicant's eligibility.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.008. ELIGIBILITY FOR SERVICES. (a) The department

shall determine an individual's eligibility for treatment

services according to this chapter and the program rules.

(b) An individual is not eligible to receive treatment services

provided under this chapter unless:

(1) the individual is a resident of this state;

(2) the department has determined that neither the individual

nor a person with a legal obligation to support the individual is

financially able to pay for all or part of the treatment services

provided by this chapter;

(3) the individual complies with any other requirements stated

in the program rules; and

(4) at least one licensed dentist or licensed physician has

certified to the department that the dentist or physician has

examined the individual and has found that:

(A) the individual meets the board's dental criteria; and

(B) the dentist or physician has reason to expect that the

treatment services provided by or through the department will

prevent or reduce the probability of the individual's

experiencing pain, infection, or disease.

(c) Except as permitted by program rules, the department may not

provide treatment services before an individual's eligibility

date assigned by the department or authorize payment for

treatment services furnished by a provider before that date.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.009. DENIAL, MODIFICATION, SUSPENSION, OR TERMINATION OF

SERVICES. (a) The department may, for cause, deny an

application for treatment services or modify, suspend, or

terminate a recipient's treatment services after notice to the

applicant or recipient and the opportunity for a due process

hearing.

(b) The board by rule shall provide criteria for action by the

department under this section.

(c) Chapter 2001, Government Code, do not apply to the granting,

denial, modification, suspension, or termination of treatment

services. The department shall conduct hearings in accordance

with the board's due process hearing rules.

(d) The department shall render the final administrative

decision in a due process hearing to deny, modify, suspend, or

terminate the receipt of oral health services.

(e) This section does not apply if oral health services are

restricted to conform to budgetary limitations as prescribed by

Section 43.004(b).

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Amended by Acts 1995, 74th Leg., ch. 76, Sec. 5.95(66), eff.

Sept. 1, 1995.

Sec. 43.010. FINANCIAL ELIGIBILITY; OTHER BENEFITS. (a) The

department shall require an individual receiving treatment

services under this chapter or a person with a legal obligation

to support the individual to pay for or reimburse the department

for that part of the cost of the treatment services that the

individual or person is financially able to pay.

(b) An individual is not eligible to receive treatment services

under this chapter to the extent that the individual or a person

with a legal obligation to support the individual is eligible for

some other benefit that would pay for all or part of the

treatment services.

(c) When the application is made under this chapter or at any

time during eligibility and the receipt of treatment services,

the applicant for or recipient of treatment services shall inform

the department of any other benefit to which the individual or a

person with a legal obligation to support the individual may be

entitled.

(d) An individual who has received treatment services that are

covered by some other benefit, or a person with a legal

obligation to support the individual, shall reimburse the

department to the extent of the treatment services provided when

the other benefit is received.

(e) The commissioner may waive the enforcement of Subsection (b)

as prescribed by board rules in certain individually considered

cases in which enforcement will deny treatment services to a

class of otherwise eligible individuals because of conflicting

federal, state, or local laws or rules.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.011. RECOVERY OF COSTS. (a) The department may recover

the cost of treatment services provided under this chapter from a

person who does not pay or reimburse the department as required

by this chapter or from any third party who has a legal

obligation to pay other benefits and to whom notice of the

department's interest has been given.

(b) At the request of the commissioner, the attorney general may

bring suit in the appropriate court of Travis County on behalf of

the department.

(c) In a judgment in favor of the department, the court may

award attorney's fees, court costs, and interest accruing from

the date on which the department provides the service to the date

on which the department is reimbursed.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.012. FEES. The board may charge fees for the oral

health services provided directly by the department or through

approved providers in accordance with Subchapter D, Chapter 12.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.013. FUNDS. (a) Subject to limitations or conditions

prescribed by the legislature, the board may seek, receive, and

spend funds received from any public or private source for the

purposes of this chapter.

(b) The department is not required to provide oral health

services unless funds are appropriated to the department for that

express purpose.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.

Sec. 43.014. CONTRACTS. The department may enter into contracts

and agreements necessary to facilitate the efficient and

economical provision of oral health services under this chapter,

including contracts for the purchase of services, equipment, and

supplies from qualified providers.

Acts 1989, 71st Leg., ch. 678, Sec. 1, eff. Sept. 1, 1989.