PRINTER'S NO. 2967
No. 2100 Session of 2007
INTRODUCED BY SAYLOR, NICKOL, MACKERETH, MELIO, WALKO, BARRAR, BELFANTI, BENNINGTON, BRENNAN, CAPPELLI, COHEN, FLECK, FREEMAN, GEIST, GEORGE, GINGRICH, HALUSKA, HARHART, HERSHEY, JOSEPHS, KOTIK, McILHATTAN, MILNE, MOYER, MUNDY, MURT, MYERS, NAILOR, M. O'BRIEN, PETRONE, RUBLEY, SIPTROTH, SOLOBAY, STABACK, STURLA, THOMAS, J. WHITE AND YOUNGBLOOD, DECEMBER 6, 2007
REFERRED TO COMMITTEE ON INSURANCE, DECEMBER 6, 2007
AN ACT 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 15 not covered by some health insurance policies, the result can
1 be treatment with compromised outcomes, parents subjected to 2 incurred expenses or treatment not performed, at the expense 3 of the child's health. 4 (5) Mandatory insurance coverage for general anesthesia 5 for dental treatment is essential to ensure that all children 6 receive the dental treatment they need to maintain good 7 health. 8 The General Assembly of the Commonwealth of Pennsylvania 9 hereby enacts as follows: 10 Section 1. Short title. 11 This act shall be known and may be cited as the Children's 12 and Special Needs Patient's Access to Quality Dental Care Act. 13 Section 2. Definitions. 14 The following words and phrases when used in this act shall 15 have the meanings given to them in this section unless the 16 context clearly indicates otherwise: 17 "Associated medical costs." Hospitalization and related 18 medical expenses, such as the administration of general 19 anesthesia when dental treatment must be performed in a dental 20 office. 21 "Dental care." The diagnosis, treatment planning and 22 implementation of services directed at the prevention and 23 treatment of diseases, conditions and dysfunctions relating to 24 the oral cavity and its associated structures and their impact 25 upon the human body, or the implementation of professional 26 dental care, which includes diagnostic, preventive, therapeutic, 27 restorative, oral and maxillofacial, surgical, endodontic, 28 prosthodontic, orthodontic, periodontic and aesthetic (cosmetic) 29 services provided to dental patients by a legally qualified 30 dentist or physician operating within the scope of the dentist's 20070H2100B2967 - 2 -
1 or physician's training. 2 "Eligible dental patient." 3 (1) A dental patient who is severely disabled mentally, 4 physically, developmentally, emotionally or behaviorally and 5 the patient is an extremely uncooperative, unmanageable, 6 anxious, fearful individual or is an uncommunicative 7 individual with dental needs deemed sufficiently important 8 that dental care cannot be deferred. 9 (2) Children under five years of age. 10 "General anesthesia." A controlled state of unconsciousness, 11 including deep sedation, that is produced by a pharmacologic 12 method, a nonpharmacologic method or a combination of both and 13 that is accompanied by a complete or partial loss of protective 14 reflexes that include the patient's inability to maintain an 15 airway independently and to respond purposefully to physical 16 stimulation or verbal command. 17 "Health care facility." Any health care facility providing 18 clinically related health services, including, but not limited 19 to, a general or special hospital, including psychiatric 20 hospitals, rehabilitation hospitals, ambulatory surgical 21 facilities, long-term care nursing facilities, cancer treatment 22 centers using radiation therapy on an ambulatory basis and 23 inpatient drug and alcohol treatment facilities, both profit and 24 nonprofit and including those operated by an agency or State or 25 local government. The term shall also include a hospice. The 26 term shall not include an office used primarily for the private 27 or group practice by health care practitioners where no 28 reviewable clinically related health service is offered, a 29 facility providing treatment solely on the basis of prayer or 30 spiritual means in accordance with the tenets of any church or 20070H2100B2967 - 3 -
1 religious denomination or a facility conducted by a religious 2 organization for the purpose of providing health care services 3 exclusively to clergy or other persons in a religious profession 4 who are members of the religious denominations conducting the 5 facility. 6 "Health insurance policy." An individual or group health, 7 sickness or accident policy, subscriber contract or certificate 8 issued by an entity subject to this act or any of the following: 9 (1) The act of May 17, 1921 (P.L.682, No.284), known as The 10 Insurance Company Law of 1921. 11 (2) The act of December 29, 1972 (P.L.1701, No.364), known 12 as the Health Maintenance Organization Act. 13 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan 14 corporations) or 63 (relating to professional health services 15 plan corporations). 16 (5) Medical assistance. 17 The term does not include any of the following types of 18 policies: accident only, fixed indemnity, limited benefit, 19 credit, dental, vision, specified disease, Medicare 20 supplemental, Civilian Health and Medical Program of the Uniform 21 Services (CHAMPUS) supplement, long-term care, disability 22 income, workers' compensation or automobile medical payment. 23 Section 3. Required coverage. 24 (a) General rule.-- 25 (1) Every health insurance policy shall cover general 26 anesthesia and associated medical costs provided to an 27 eligible dental patient. 28 (2) A health insurance carrier may require authorization 29 of hospitalization for dental care procedures in the same 30 manner that prior authorization is required for 20070H2100B2967 - 4 -
1 hospitalization for other covered diseases or conditions. 2 (3) A policy of accident and health insurance providing 3 coverage to a resident of this Commonwealth must also provide 4 coverage for general anesthesia and associated medical costs 5 derived by its administration and billed by a dentist for an 6 eligible dental patient excluding dental care covered under 7 the health plan, regardless of whether the services are 8 provided in a health care facility or a dental office. 9 (4) This act shall not be construed to require coverage 10 for the dental care for which the general anesthesia is 11 provided. 12 (5) The provisions of this act shall not apply to dental 13 care rendered for temporal mandibular joint disorders. 14 (b) Coverage subject to annual deductible, copayment or 15 coinsurance requirements.--The coverage required under this act 16 shall be subject to the annual deductible, copayment or 17 coinsurance requirements imposed by an entity subject to this 18 act for similar coverages under the same health insurance policy 19 or contract. 20 Section 4. Delivery of policy. 21 If a health insurance policy provides coverage or benefits to 22 a resident of this Commonwealth, it shall be deemed to be 23 delivered in this Commonwealth within the meaning of this act, 24 regardless of whether the health care insurer issuing or 25 delivering the policy is located within or outside this 26 Commonwealth. 27 Section 5. Repeals. 28 All acts and parts of acts are repealed insofar as they are 29 inconsistent with this act. 30 Section 6. Applicability. 20070H2100B2967 - 5 -
1 This act shall apply to all health insurance policies issued 2 under any group master policy or individual policy delivered or 3 issued for delivery on or after the effective date of this act 4 only to residents of this Commonwealth and to renewals of such 5 policies on or after the effective date of this act. 6 Section 7. Effective date. 7 This act shall take effect in 180 days. J22L40JLW/20070H2100B2967 - 6 -