PRINTER'S NO. 1035
No. 879 Session of 2003
INTRODUCED BY SAYLOR, NICKOL, DeLUCA, MACKERETH, SATHER, ADOLPH,
BEBKO-JONES, TANGRETTI, BAKER, BARRAR, BELARDI, BELFANTI,
BENNINGHOFF, CAPPELLI, CRUZ, CURRY, FREEMAN, GEIST, GEORGE,
JAMES, JOSEPHS, KIRKLAND, McCALL, McILHATTAN, MUNDY, NAILOR,
PAYNE, READSHAW, REICHLEY, ROBERTS, SCRIMENTI, SOLOBAY,
STABACK, E. Z. TAYLOR, THOMAS AND YOUNGBLOOD, MARCH 13, 2003
REFERRED TO COMMITTEE ON INSURANCE, MARCH 13, 2003
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
16 be treatment with compromised outcomes, parents subjected to
1 incurred expenses or treatment not performed, at the expense
2 of the child's health.
3 (5) Mandatory insurance coverage for general anesthesia
4 for dental treatment is essential to ensure that all children
5 receive the dental treatment they need to maintain good
6 health.
7 The General Assembly of the Commonwealth of Pennsylvania
8 hereby enacts as follows:
9 Section 1. Short title.
10 This act shall be known and may be cited as the Children's
11 and Special Needs Patient's Access to Quality Dental Care Act.
12 Section 2. Definitions.
13 The following words and phrases when used in this act shall
14 have the meanings given to them in this section unless the
15 context clearly indicates otherwise:
16 "Associated medical costs." Hospitalization and related
17 medical expenses, such as the administration of general
18 anesthesia when dental treatment must be performed in a dental
19 office.
20 "Dental care." The diagnosis, treatment planning and
21 implementation of services directed at the prevention and
22 treatment of diseases, conditions and dysfunctions relating to
23 the oral cavity and its associated structures and their impact
24 upon the human body, or the implementation of professional
25 dental care, which includes diagnostic, preventive, therapeutic,
26 restorative, oral and maxillofacial, surgical, endodontic,
27 prosthodontic, orthodontic, periodontic and aesthetic (cosmetic)
28 services provided to dental patients by a legally qualified
29 dentist or physician operating within the scope of the dentist's
30 or physician's training.
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1 "Eligible dental patient."
2 (1) A dental patient who is severely disabled mentally,
3 physically, developmentally, emotionally or behaviorally and
4 the patient is an extremely uncooperative, unmanageable,
5 anxious, fearful individual or is an uncommunicative
6 individual with dental needs deemed sufficiently important
7 that dental care cannot be deferred.
8 (2) Children under five years of age.
9 "General anesthesia." A controlled state of unconsciousness,
10 including deep sedation, that is produced by a pharmacologic
11 method, a nonpharmacologic method or a combination of both and
12 that is accompanied by a complete or partial loss of protective
13 reflexes that include the patient's inability to maintain an
14 airway independently and to respond purposefully to physical
15 stimulation or verbal command.
16 "Health care facility." Any health care facility providing
17 clinically related health services, including, but not limited
18 to, a general or special hospital, including psychiatric
19 hospitals, rehabilitation hospitals, ambulatory surgical
20 facilities, long-term care nursing facilities, cancer treatment
21 centers using radiation therapy on an ambulatory basis and
22 inpatient drug and alcohol treatment facilities, both profit and
23 nonprofit and including those operated by an agency or State or
24 local government. The term shall also include a hospice. The
25 term shall not include an office used primarily for the private
26 or group practice by health care practitioners where no
27 reviewable clinically related health service is offered, a
28 facility providing treatment solely on the basis of prayer or
29 spiritual means in accordance with the tenets of any church or
30 religious denomination or a facility conducted by a religious
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1 organization for the purpose of providing health care services
2 exclusively to clergy or other persons in a religious profession
3 who are members of the religious denominations conducting the
4 facility.
5 "Health insurance policy." An individual or group health,
6 sickness or accident policy, subscriber contract or certificate
7 issued by an entity subject to this act or any of the following:
8 (1) The act of May 17, 1921 (P.L.682, No.284), known as The
9 Insurance Company Law of 1921.
10 (2) The act of December 29, 1972 (P.L.1701, No.364), known
11 as the Health Maintenance Organization Act.
12 (4) 40 Pa.C.S. Ch. 61 (relating to hospital plan
13 corporations) or 63 (relating to professional health services
14 plan corporations).
15 (5) Medical assistance.
16 The term does not include any of the following types of
17 policies: accident only, fixed indemnity, limited benefit,
18 credit, dental, vision, specified disease, Medicare
19 supplemental, Civilian Health and Medical Program for the
20 Uniform Services (CHAMPUS) supplement, long-term care,
21 disability income, workers' compensation or automobile medical
22 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
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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) The guardian or parent of an eligible dental patient
10 may require the dental work and anesthesia to be performed in
11 a health care facility regardless of the opinion of the
12 dentist.
13 (5) This act shall not be construed to require coverage
14 for the dental care for which the general anesthesia is
15 provided.
16 (6) The provisions of this act shall not apply to dental
17 care rendered for temporal mandibular joint disorders.
18 (b) Coverage subject to annual deductibles or coinsurance
19 requirements.--The coverage required under this act shall be
20 subject to the annual deductibles or coinsurance requirements
21 imposed by an entity subject to this act for similar coverages
22 under the same health insurance policy or contract.
23 Section 4. Delivery of policy.
24 If a health insurance policy provides coverage or benefits to
25 a resident of this Commonwealth, it shall be deemed to be
26 delivered in this Commonwealth within the meaning of this act,
27 regardless of whether the health care insurer issuing or
28 delivering the policy is located within or outside this
29 Commonwealth.
30 Section 5. Repeals.
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1 All acts and parts of acts are repealed insofar as they are
2 inconsistent with this act.
3 Section 6. Applicability.
4 This act shall apply to all health insurance policies issued
5 under any group master policy or individual policy delivered or
6 issued for delivery on or after the effective date of this act
7 only to residents of this Commonwealth and to renewals of such
8 policies on or after the effective date of this act.
9 Section 7. Effective date.
10 This act shall take effect in 180 days.
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