THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY SAYLOR, BARRAR, BOBACK, CALTAGIRONE, COHEN, D. COSTA, CUTLER, DAY, DeLUCA, DERMODY, DiGIROLAMO, EVERETT, FLECK, GEIST, GILLEN, GINGRICH, GROVE, HARHAI, HARHART, HARKINS, HARPER, HESS, HORNAMAN, JOSEPHS, KIRKLAND, KOTIK, MARSHALL, MARSICO, MILLER, MURT, MYERS, O'NEILL, PICKETT, PYLE, RAPP, REICHLEY, STABACK, STURLA, SWANGER, J. TAYLOR, VEREB, VULAKOVICH AND WATSON, FEBRUARY 8, 2011

REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 8, 2011  

AN ACT

Providing mandatory insurance coverage for general anesthesia.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1.  Short title.

This act shall be known and may be cited as the Children and

Special Needs Patient Access to Quality Dental Care Act.

Section 2.  Definitions.

The following words and phrases when used in this act shall

have the meanings given to them in this section unless the

context clearly indicates otherwise:

"Associated medical costs."  Hospitalization and all related

medical expenses normally incurred as a result of the

administration of general anesthesia in a dental office,

hospital setting or any facility in which the administration of

general anesthesia in connection with dental care is permitted.

"Carrier."  An entity that sells or offers to sell health

insurance policies in this Commonwealth.

"Dental care."  The diagnosis, treatment planning and

implementation of services directed at the prevention and

treatment of diseases, conditions and dysfunctions relating to

the oral cavity and its associated structures and their impact

upon the human body or the implementation of professional dental

care, which includes diagnostic, preventative, therapeutic,

restorative, oral and maxillofacial, surgical, endodontic,

prosthodontic, orthodontic and periodontic services provided to

dental patients by a legally qualified dentist or physician

operating within the scope of the dentist's or physician's

training and licensure.

"Eligible dental patient."  A patient who is seven years of

age or younger or developmentally disabled for whom a successful

result cannot be expected for treatment under local anesthesia

and for whom a superior result can be expected for treatment

under general anesthesia.

"General anesthesia."  A controlled state of unconsciousness,

including deep sedation, that is produced by a pharmacologic

method, a nonpharmacologic method or a combination of both and

that is accompanied by a complete or partial loss of protective

reflexes that include the patient's inability to maintain an

airway independently and to respond purposefully to physical

stimulation or verbal command.

"Health care facility."  A health care facility that provides

clinically related health services, including, but not limited

to general or specific hospital, psychiatric hospital,

rehabilitation hospital, a facility in which the administration

of general anesthesia in connection with dental care is

permitted, ambulatory surgical facility, long-term care nursing

facility, cancer treatment center using radiation therapy on an

ambulatory basis and an inpatient drug and alcohol treatment

facility, both profit and nonprofit, and including any such

facility operated by an agency or State or local government. The

term shall also include a hospice. The term shall not include a

facility that provides treatment solely on the basis of prayer

or spiritual means in accordance with the tenets of a church or

religious denomination or a facility conducted by a religious

organization for the purpose of providing health care services

exclusively to clergy or other persons in a religious profession

who are members of the religious denomination operating the

facility.

"Health insurance policy."  An individual or group health,

sickness or accident policy, subscriber contract or certificate

issued by an entity subject to this act or any of the following:

(1)  The act of May 17, 1921 (P.L.682, No.284), known as

The Insurance Company Law of 1921.

(2)  The act of December 29, 1972 (P.L.1701, No.364),

known as the Health Maintenance Organization Act.

(3)  40 Pa.C.S. Ch. 61 (relating to hospital plan

corporations) or 63 (relating to professional health services

plan corporations).

(4)  Medical assistance.

The term does not include any of the following types of

policies: accident only, fixed indemnity, limited benefit,

credit, dental, vision, specified disease, Medicare

supplemental, Civilian Heath and Medical Program of the Uniform

Services (CHAMPUS) supplement, long-term care, disability

income, workers' compensation or automobile medical payment.

Section 3.  Required coverage.

(a)  General rule.--

(1)  Every health insurance policy shall cover general

anesthesia and associated medical costs provided to an

eligible dental patient.

(2)  A carrier may require prior authorization in

accordance with the carrier's health insurance policy and

requirements.

(3)  A policy of accident and health insurance providing

coverage to a resident of this Commonwealth must also provide

coverage for general anesthesia and associated medical costs

associated with its administration and must be billed by a

dentist for an eligible dental patient, excluding dental care

covered under the health plan, regardless of whether the

services are provided in a health care facility or a dental

office.

(b)  Coverage subject to annual deductible, copayment or

coinsurance requirements.--The coverage required under this act

shall be subject to the annual deductible, copayment or

coinsurance requirements imposed by an entity subject to this

act for similar coverages under the same health insurance policy

or contract.

(c)  Construction.--This act shall not be construed to

require coverage for dental care for which general anesthesia is

provided.

(d)  Nonapplicability.-The provisions of this section shall

not apply to dental care rendered for temporal mandibular joint

disorders.

Section 4.  Repeals.

All acts and parts of acts are repealed insofar as they are

inconsistent with this act.

Section 5.  Applicability.

This act shall apply to all health insurance policies issued

under any group master policy or individual policy delivered or

issued for delivery on or after the effective date of this

section only to residents of this Commonwealth and to renewals

of such policies on or after the effective date of this section.

Section 6.  Effective date.

This act shall take effect in 180 days.