HEALTH & SAFETY CODE
CHAPTER 43. ORAL HEALTH IMPROVEMENT
§ 43.001. SHORT TITLE. This chapter may be cited as the
Texas Oral Health Improvement Act.
Acts 1989, 71st Leg., ch. 678, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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. § 1395 et seq. and 42 U.S.C.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(66), eff. Sept. 1, 1995.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989. Amended
by Acts 1995, 74th Leg., ch. 76, § 5.95(66), eff. Sept. 1, 1995.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
§ 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, § 1, eff. Sept. 1, 1989.
