PRINTER'S NO. 1252
No. 1093 Session of 2001
INTRODUCED BY SAYLOR, VANCE, NICKOL, MACKERETH, BLAUM,
FAIRCHILD, HERMAN, ARGALL, M. BAKER, BARD, BELARDI, BELFANTI,
BROWNE, BUNT, CALTAGIRONE, CAPPABIANCA, L. I. COHEN,
M. COHEN, CORNELL, CRUZ, DALLY, DeLUCA, FEESE, FREEMAN,
GEIST, GEORGE, HALUSKA, HARHAI, HENNESSEY, HESS, JOSEPHS,
LYNCH, McCALL, McILHATTAN, McILHINNEY, McNAUGHTON, MELIO,
R. MILLER, MYERS, PHILLIPS, PISTELLA, SATHER, SCRIMENTI,
SHANER, SOLOBAY, STABACK, STEELMAN, E. Z. TAYLOR, J. TAYLOR,
TIGUE, TRELLO, WALKO, WILT, WOJNAROSKI AND ZUG,
MARCH 20, 2001
REFERRED TO COMMITTEE ON INSURANCE, MARCH 20, 2001
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
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 101. 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 102. 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, periodontic and aesthetic (cosmetic)
30 services provided to dental patients by a legally qualified
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1 dentist or physician operating within the scope of the dentist's
2 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 "General anesthesia." A controlled state of unconsciousness,
12 including deep sedation, that is produced by a pharmacologic
13 method, a nonpharmacologic method or a combination of both and
14 that is accompanied by a complete or partial loss of protective
15 reflexes that include the patient's inability to maintain an
16 airway independently and to respond purposefully to physical
17 stimulation or verbal command.
18 "Health care facility." Any health care facility providing
19 clinically related health services, including, but not limited
20 to, a general or special hospital, including psychiatric
21 hospitals, rehabilitation hospitals, ambulatory surgical
22 facilities, long-term care nursing facilities, cancer treatment
23 centers using radiation therapy on an ambulatory basis and
24 inpatient drug and alcohol treatment facilities, both profit and
25 nonprofit and including those operated by an agency or State or
26 local government. The term shall also include a hospice. The
27 term shall not include an office used primarily for the private
28 or group practice by health care practitioners where no
29 reviewable clinically related health service is offered, a
30 facility providing treatment solely on the basis of prayer or
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1 spiritual means in accordance with the tenets of any church or
2 religious denomination or a facility conducted by a religious
3 organization for the purpose of providing health care services
4 exclusively to clergy or other persons in a religious profession
5 who are members of the religious denominations conducting the
6 facility.
7 "Health insurance policy." An individual or group health,
8 sickness or accident policy, subscriber contract or certificate
9 issued by an entity subject to this act or any of the following:
10 (1) The act of May 17, 1921 (P.L.682, No.284), known as The
11 Insurance Company Law of 1921.
12 (2) The act of December 29, 1972 (P.L.1701, No.364), known
13 as the Health Maintenance Organization Act.
14 (3) The act of December 14, 1992 (P.L.835, No.134), known as
15 the Fraternal Benefit Societies Code.
16 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
17 corporations) or 63 (relating to professional health services
18 plan corporations).
19 (5) Medical assistance.
20 The term does not include any of the following types of
21 policies: accident only, fixed indemnity, limited benefit,
22 credit, dental, vision, specified disease, Medicare
23 supplemental, Civilian Health and Medical Program for the
24 Uniform Services (CHAMPUS) supplement, long-term care,
25 disability income, workers' compensation or automobile medical
26 payment.
27 Section 103. Required coverage.
28 (a) General rule.--
29 (1) Every health insurance policy shall cover general
30 anesthesia and associated medical costs provided to an
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1 eligible dental patient.
2 (2) A health insurance carrier may require authorization
3 of hospitalization for dental care procedures in the same
4 manner that prior authorization is required for
5 hospitalization for other covered diseases or conditions.
6 (3) A policy of accident and health insurance providing
7 coverage to a resident of this Commonwealth must also provide
8 coverage for general anesthesia and associated medical costs
9 derived by its administration and billed by a dentist for an
10 eligible dental patient excluding dental care covered under
11 the health plan, regardless of whether the services are
12 provided in a health care facility or a dental office.
13 (4) The guardian or parent of an eligible dental patient
14 may require the dental work and anesthesia to be performed in
15 a health care facility regardless of the opinion of the
16 dentist.
17 (5) This act shall not be construed to require coverage
18 for the dental care for which the general anesthesia is
19 provided.
20 (6) The provisions of this act shall not apply to dental
21 care rendered for temporal mandibular joint disorders.
22 (b) Coverage subject to annual deductibles or coinsurance
23 requirements.--The coverage required under this act shall be
24 subject to the annual deductibles or coinsurance requirements
25 imposed by an entity subject to this act for similar coverages
26 under the same health insurance policy or contract.
27 Section 104. Delivery of policy.
28 If a health insurance policy provides coverage or benefits to
29 a resident of this Commonwealth, it shall be deemed to be
30 delivered in this Commonwealth within the meaning of this act,
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1 regardless of whether the health care insurer issuing or
2 delivering the policy is located within or outside this
3 Commonwealth.
4 Section 105. Repeals.
5 All acts and parts of acts are repealed insofar as they are
6 inconsistent with this act.
7 Section 106. Applicability.
8 This act shall apply to all health insurance policies issued
9 under any group master policy or individual policy delivered or
10 issued for delivery on or after the effective date of this act
11 only to residents of this Commonwealth and to renewals of such
12 policies on or after the effective date of this act.
13 Section 107. Effective date.
14 This act shall take effect in 180 days.
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