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| PRIOR PRINTER'S NO. 1220 | PRINTER'S NO. 2769 |
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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| INTRODUCED BY SAYLOR, BAKER, BARRAR, BELFANTI, BEYER, BRENNAN, BRIGGS, CASORIO, CREIGHTON, DERMODY, DiGIROLAMO, FAIRCHILD, FLECK, FREEMAN, GEIST, GEORGE, GIBBONS, GINGRICH, GROVE, HALUSKA, HARHART, HARPER, HELM, HESS, HORNAMAN, KORTZ, KOTIK, MAHER, MAHONEY, MELIO, METZGAR, MILLARD, MILLER, MOUL, MUNDY, MURT, M. O'BRIEN, O'NEILL, PICKETT, QUINN, RAPP, READSHAW, REICHLEY, SIPTROTH, K. SMITH, SOLOBAY, STABACK, STURLA, VULAKOVICH, WALKO, WANSACZ, WATSON AND GALLOWAY, MARCH 23, 2009 |
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| AS REPORTED FROM COMMITTEE ON INSURANCE, HOUSE OF REPRESENTATIVES, AS AMENDED, OCTOBER 7, 2009 |
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| AN ACT |
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1 | Providing mandatory insurance coverage for general anesthesia |
2 | for dental care for certain persons. |
3 | The General Assembly finds and declares as follows: | <-- |
4 | (1) Tooth decay is the single most common chronic |
5 | disease of childhood. Dental treatment for children is |
6 | imperative to maintain their health. |
7 | (2) Children suffer significant morbidity from tooth |
8 | decay, including pain, infection, dysfunction, poor |
9 | appearance and missed school days. |
10 | (3) The necessity for dentists to utilize general |
11 | anesthesia may occur on the very young, disabled or special |
12 | needs patients, where the dental treatment is not deemed |
13 | possible without general anesthesia by the dentist. |
14 | (4) Because general anesthesia for dental treatment is |
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1 | not covered by some health insurance policies, the result can |
2 | be treatment with compromised outcomes, parents subjected to |
3 | incurred expenses or treatment not performed at the expense |
4 | of the child's health. |
5 | (5) Mandatory insurance coverage for general anesthesia |
6 | for dental treatment is essential to ensure that all children |
7 | receive the dental treatment they need to maintain good |
8 | health. |
9 | The General Assembly of the Commonwealth of Pennsylvania |
10 | hereby enacts as follows: |
11 | Section 1. Short title. |
12 | This act shall be known and may be cited as the Children's |
13 | and Special Needs Patient's Access to Quality Dental Care Act. |
14 | Section 2. Definitions. |
15 | The following words and phrases when used in this act shall |
16 | have the meanings given to them in this section unless the |
17 | context clearly indicates otherwise: |
18 | "Associated medical costs." Hospitalization and related |
19 | medical expenses, such as the administration of general |
20 | anesthesia when dental treatment must be performed in a dental |
21 | office. |
22 | "Dental care." The diagnosis, treatment planning and |
23 | implementation of services directed at the prevention and |
24 | treatment of diseases, conditions and dysfunctions relating to |
25 | the oral cavity and its associated structures and their impact |
26 | upon the human body, or the implementation of professional |
27 | dental care, which includes diagnostic, preventive, therapeutic, |
28 | restorative, oral and maxillofacial, surgical, endodontic, |
29 | prosthodontic, orthodontic, and periodontic and aesthetic | <-- |
30 | (cosmetic) services provided to dental patients by a legally |
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1 | qualified dentist or physician operating within the scope of the |
2 | dentist or physician's training. |
3 | "Eligible dental patient." | <-- |
4 | (1) A dental patient who is severely disabled mentally, |
5 | physically, developmentally, emotionally or behaviorally, and |
6 | the patient is an extremely uncooperative, unmanageable, |
7 | anxious, fearful individual or is an uncommunicative |
8 | individual with dental needs deemed sufficiently important |
9 | that dental care cannot be deferred. |
10 | (2) Children under five years of age. |
11 | "Eligible dental patient." An individual who meets all of | <-- |
12 | the following: |
13 | (1) is seven years of age or younger or is |
14 | developmentally disabled; |
15 | (2) is an individual for whom a successful result cannot |
16 | be expected from dental care provided under local anesthesia |
17 | because of a physical, intellectual or other medically |
18 | compromising condition of the enrollee or insured; and |
19 | (3) is an individual for whom a superior result can be |
20 | expected from dental care provided under general anesthesia. |
21 | "General anesthesia." A controlled state of unconsciousness, |
22 | including deep sedation, that is produced by a pharmacologic |
23 | method, a nonpharmacologic method or a combination of both and |
24 | that is accompanied by a complete or partial loss of protective |
25 | reflexes that include the patient's inability to maintain an |
26 | airway independently and to respond purposefully to physical |
27 | stimulation or verbal command. |
28 | "Health care facility." Any health care facility providing |
29 | clinically related health services, including, but not limited |
30 | to, a general or special hospital, including psychiatric |
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1 | hospitals, rehabilitation hospitals, ambulatory surgical |
2 | facilities, long-term care nursing facilities, cancer treatment |
3 | centers using radiation therapy on an ambulatory basis and |
4 | inpatient drug and alcohol treatment facilities, both profit and |
5 | nonprofit and including those operated by an agency or State or |
6 | local government. The term shall also include a hospice. The |
7 | term shall not include an office used primarily for the private |
8 | or group practice by health care practitioners where no |
9 | reviewable clinically related health service is offered, a |
10 | facility providing treatment solely on the basis of prayer or |
11 | spiritual means in accordance with the tenets of any church or |
12 | religious denomination or a facility conducted by a religious |
13 | organization for the purpose of providing health care services |
14 | exclusively to clergy or other persons in a religious profession |
15 | who are members of the religious denominations conducting the |
16 | facility. |
17 | "Health insurance policy." An individual or group health, |
18 | sickness or accident policy, subscriber contract or certificate |
19 | issued by an entity subject to this act or any of the following: |
20 | (1) The act of May 17, 1921 (P.L.682, No.284), known as |
21 | The Insurance Company Law of 1921. |
22 | (2) The act of December 29, 1972 (P.L.1701, No.364), |
23 | known as the Health Maintenance Organization Act. |
24 | (4) (3) 40 Pa.C.S. Ch. 61 (relating to hospital plan | <-- |
25 | corporations) or 63 (relating to professional health services |
26 | plan corporations). |
27 | (5) (4) Medical assistance. | <-- |
28 | The term does not include any of the following types of |
29 | policies: accident only, fixed indemnity, limited benefit, |
30 | credit, dental, vision, specified disease, Medicare |
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1 | supplemental, Civilian Health and Medical Program of the Uniform |
2 | Services (CHAMPUS) supplement, long-term care, disability |
3 | income, workers' compensation or automobile medical payment. |
4 | Section 3. Required coverage. |
5 | (a) General rule.-- |
6 | (1) Every health insurance policy shall cover general |
7 | anesthesia and associated medical costs provided to an |
8 | eligible dental patient. |
9 | (2) A health An insurance carrier may require prior | <-- |
10 | authorization of hospitalization for dental care procedures | <-- |
11 | in the same manner that prior authorization is required for |
12 | hospitalization for other covered diseases or conditions. in | <-- |
13 | accordance with the carrier's health insurance policy and |
14 | requirements. |
15 | (3) A policy of accident and health insurance providing |
16 | coverage to a resident of this Commonwealth must also provide |
17 | coverage for general anesthesia and associated medical costs |
18 | derived by its administration and billed by a dentist for an |
19 | eligible dental patient, excluding dental care covered under |
20 | the health plan, regardless of whether the services are |
21 | provided in a health care facility or a dental office. |
22 | (4) This act shall not be construed to require coverage |
23 | for the dental care for which the general anesthesia is |
24 | provided. |
25 | (5) The provisions of this act shall not apply to dental |
26 | care rendered for temporal mandibular joint disorders. |
27 | (b) Coverage subject to annual deductible, copayment or |
28 | coinsurance requirements.--The coverage required under this act |
29 | shall be subject to the annual deductible, copayment or |
30 | coinsurance requirements imposed by an entity subject to this |
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1 | act for similar coverages under the same health insurance policy |
2 | or contract. |
3 | Section 4. Delivery of policy. | <-- |
4 | If a health insurance policy provides coverage or benefits to |
5 | a resident of this Commonwealth, it shall be deemed to be |
6 | delivered in this Commonwealth within the meaning of this act, |
7 | regardless of whether the health care insurer issuing or |
8 | delivering the policy is located within or outside this |
9 | Commonwealth. |
10 | Section 5 4. Repeals. | <-- |
11 | All acts and parts of acts are repealed insofar as they are |
12 | inconsistent with this act. |
13 | Section 6 5. Applicability. | <-- |
14 | This act shall apply to all health insurance policies issued |
15 | under any group master policy or individual policy delivered or |
16 | issued for delivery on or after the effective date of this |
17 | section only to residents of this Commonwealth and to renewals |
18 | of such policies on or after the effective date of this section. |
19 | Section 20. Effective date. |
20 | This act shall take effect in 180 days. |
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