PRINTER'S NO. 1032
No. 901 Session of 1985
INTRODUCED BY LAUGHLIN, TRUMAN, CESSAR, TRELLO, McCALL,
PISTELLA, DeLUCA, WAMBACH, MARKOSEK, MAYERNIK, BELFANTI,
BOWLEY, LIVENGOOD, HUTCHINSON, PRESTON, FREEMAN, FATTAH,
BARBER, RIEGER, STEWART, McHALE, O'BRIEN, KENNEY, WOGAN,
WESTON, DURHAM, BOWSER, FREIND AND COWELL, APRIL 16, 1985
REFERRED TO COMMITTEE ON HEALTH AND WELFARE, APRIL 16, 1985
AN ACT
1 Establishing a program of limited dental assistance for the
2 elderly; granting powers to and imposing duties on the
3 Department of Aging; establishing a payment system; making
4 provisions for funding; providing for reports; and fixing
5 penalties for violations of the dental assistance program.
6 The General Assembly of the Commonwealth of Pennsylvania
7 hereby enacts as follows:
8 Section 1. Short title.
9 This act shall be known and may be cited as the Dental
10 Assistance for the Elderly Act.
11 Section 2. Legislative findings.
12 Finding that an increasing number of the Commonwealth's
13 elderly citizens who are living on fixed incomes are
14 experiencing difficulties in meeting the costs of necessary
15 dental care, the General Assembly, in its responsibilities to
16 provide for the health, welfare and safety of its residents,
17 establishes a limited State Dental Assistance Program for the
18 Elderly.
1 Section 3. Definitions.
2 The following words and phrases when used in this act shall
3 have the meanings given to them in this section unless the
4 context clearly indicates otherwise:
5 "Board." The Dental Assistance Review Board.
6 "Dental services." The general and usual services rendered
7 and care administered by dentists as defined in the act of May
8 1, 1933 (P.L.216, No.76), known as The Dental Law.
9 "Dentist." A licensed doctor of dental surgery or doctor of
10 dental medicine.
11 "Department." The Department of Aging of the Commonwealth.
12 "Eligible claimant." A resident of this Commonwealth 65
13 years of age or older, whose annual income is less than the
14 maximum annual income, and who is not otherwise qualified for
15 public assistance under the act of June 13, 1967 (P.L.31,
16 No.21), known as the Public Welfare Code.
17 "Income." All income from whatever source derived,
18 including, but not limited to, salaries, wages, bonuses,
19 commissions, income from self-employment, alimony, support
20 money, cash public assistance and relief, the gross amount of
21 any pensions of annuities, including railroad retirement
22 benefits, all benefits received under the Federal Social
23 Security Act (Public Law 74-271, U.S.C. § 301 et. seq.), (except
24 Medicare benefits), all benefits received under State employment
25 insurance laws and veterans' disability payments, all interest,
26 realized capital gains, rentals, workmen's compensation and the
27 gross amount of loss of time insurance benefits, life insurance
28 benefits and proceeds, except the first $5,000 of the total of
29 death benefits payments, and gifts of cash or property, other
30 than transfers by gift between members of a household, in excess
19850H0901B1032 - 2 -
1 of a total value of $300, but shall not include surplus food or
2 other relief in kind supplied by a government agency or property
3 tax rebate.
4 "Maximum annual income." Annual income as determined by the
5 department. Maximum annual income shall not exceed $12,000 in
6 the case of single persons or $15,000 in the case of the
7 combined annual income of married persons.
8 "Program." The Dental Assistance Program for the Elderly
9 established by this act.
10 "Usual fee." The fee which an individual dentist most
11 frequently charges to the majority of patients for the dental
12 service performed.
13 Section 4. Powers and duties of department.
14 (a) Determination of eligibility.--The department shall
15 adopt regulations relating to the determination of eligibility
16 of prospective claimants and dentists and the determination and
17 elimination of program abuse. The department shall have the
18 power to declare ineligible any claimant who abuses or misuses
19 the established dental program. The department shall have the
20 power to investigate cases of suspected dentist or recipient
21 fraud.
22 (b) Reduced assistance.--Any eligible claimant not otherwise
23 qualified for payment of dental care under any public assistance
24 program whose dental care is covered in part by any other plan
25 of assistance or insurance may be required to receive reduced
26 assistance under this act at the discretion of the department.
27 (c) Contracts.--The department is authorized to enter into
28 such contracts as are necessary to implement this act.
29 (d) Reports by department.--The department shall maintain
30 monthly statistical records on the program to effectively
19850H0901B1032 - 3 -
1 determine the cost of the program, level of participation and
2 any patterns of unusual usage. Based upon this information, the
3 department shall submit a report every three months to the Aging
4 and Youth Committee in the Senate, the Health and Welfare
5 Committee in the House of Representatives and the Dental
6 Assistance Review Board. The quarterly report shall contain, but
7 is not limited to, all information relating to the number of
8 persons served by the program, their counties of residence, a
9 breakdown of the numbers and kinds of dental services provided,
10 and the cost of each dental procedure.
11 (e) Complaint procedures.--The department shall establish
12 guidelines and a methodology to resolve complaints brought by an
13 eligible claimant or a dentist arising out of the dental
14 treatment of an eligible claimant.
15 Section 5. Funding.
16 The Department of Revenue shall annually transmit such funds
17 as are appropriated by the General Assembly from the State
18 Lottery Fund to the State Treasurer, to be deposited by the
19 State Treasurer in the Dental Assistance Program for the Elderly
20 Fund, which is hereby created. The funds shall be used only to
21 carry out the provisions of this act. Any amount in the Dental
22 Assistance Program for the Elderly Fund not expended in the
23 fiscal year for which it was appropriated shall remain in the
24 Dental Assistance Program for the Elderly Fund for use in the
25 next fiscal year, and shall not lapse.
26 Section 6. Dental Assistance Review Board.
27 (a) Establishment.--A Dental Assistance Review Board is
28 hereby established to ensure that the program provides the
29 assistance intended in a fiscally responsible manner.
30 (b) Composition.--The board shall be comprised of the
19850H0901B1032 - 4 -
1 following seven persons:
2 (1) The Secretary of Aging, who shall serve as its
3 chairman.
4 (2) The Secretary of Revenue.
5 (3) The Secretary of Health.
6 (4) Four public members, one appointed by the President
7 pro tempore of the Senate, one appointed by the Minority
8 Leader of the Senate, one appointed by the Speaker of the
9 House of Representatives and one appointed by the Minority
10 Leader of the House of Representatives. The appointed members
11 shall include two senior citizens and two representatives of
12 the dental profession, both of whom are practicing
13 Pennsylvania dentists.
14 (c) Review.--Using the quarterly reports submitted by the
15 department under section 4 and other appropriate data sources,
16 the board shall conduct a quarterly review. The board shall
17 adopt a report concerning any recommended changes in the
18 structure or operation of the program.
19 Section 7. Program provisions.
20 (a) Program criteria.--The program shall include the
21 following criteria:
22 (1) All dental services necessary for the dental and
23 general health of eligible claimants shall be eligible for
24 payment under the program.
25 (2) Any dentist who elects to treat eligible claimants
26 under the program shall agree to accept 85% of his usual fee
27 as payment in full for any dental service, any part of which
28 is paid for under the program.
29 (3) Payments under the program shall be made directly to
30 dentists.
19850H0901B1032 - 5 -
1 (4) Payments shall be equal to 85% of the usual fee of a
2 dentist for dental services performed for an eligible
3 claimant until the payments in any calendar year total $100
4 on behalf of an eligible claimant. Payments shall then be
5 equal to 50% of 85% of the usual fee of a dentist for dental
6 services performed for an eligible claimant, until the total
7 payments made on behalf of an eligible claimant in the
8 calendar year equal $200. The maximum amount of dental
9 assistance payable on behalf of any eligible claimant shall
10 not exceed $200 in any calendar year.
11 (5) All legally qualified dentists licensed to practice
12 in this Commonwealth may elect to provide dental services to
13 eligible claimants.
14 (6) Eligible claimants shall not be required to maintain
15 records of dental services paid for under the program, except
16 for a record or receipt of a copayment or any portion thereof
17 made for dental services. Payments made by claimants in
18 excess of $100 in any calendar year will not have to be
19 documented for the department.
20 (7) All dental services provided by dentists to
21 claimants shall be in accordance with the best professional
22 dental service practice in the community at the time.
23 (8) An eligible claimant shall be required to pay that
24 part of 85% of the usual fee for a dental service not paid
25 for under the program.
26 (9) All payments under the program shall be made within
27 30 days after the receipt of a properly completed and signed
28 voucher.
29 (b) Program limitations.--Payments under the program shall
30 not be made for the following:
19850H0901B1032 - 6 -
1 (1) Services by a dentist for which no charge is
2 incurred.
3 (2) Charges for failing to keep a dental appointment or
4 for completing a claim or voucher form.
5 (3) Services received prior to the effective date of the
6 program.
7 (4) Services for any occupational condition, ailment or
8 injury arising out of and in the course of covered employment
9 under worker's compensation, occupational disease laws,
10 Federal employers' liability acts, or other similar State or
11 Federal legislation, or services provided without cost to the
12 employee by any Federal, State, county or municipal hospital,
13 agency or instrumentality.
14 (5) Services which are eligible for payment under any
15 hospitalization, surgical or major medical insurance program.
16 (6) Services for which coverage is available under the
17 Federal supplementary medical insurance program for the aged
18 and disabled or any other governmental program whether
19 Federal, State or local.
20 (7) Services in a hospital performed by a dentist who in
21 any case is compensated by the hospital for similar services
22 when performed for patients.
23 (8) Services for which the eligible claimant recovers
24 the cost by legal action or settlement.
25 (c) Limitations on payments for full and partial dentures.--
26 Payments under the program shall be made for a full or partial
27 denture which would replace an existing dental appliance only
28 under the following conditions:
29 (1) The existing dental appliance cannot be
30 satisfactorily adjusted, altered, repaired or relined.
19850H0901B1032 - 7 -
1 (2) The existing dental appliance is at least five years
2 old.
3 (3) The department may waive the provisions of
4 paragraphs (1) and (2) if necessary for the proper dental
5 treatment of an eligible claimant.
6 (d) Reporting and payment procedures.--The department shall
7 develop a voucher form for the reporting of dental services for
8 eligible claimants under this act. The voucher form shall
9 include, but not be limited to, the following:
10 (1) A listing of the dental service or services
11 performed using the Code on Dental Procedures and
12 Nomenclature of the American Dental Association, the date or
13 dates on which the dental service or services were performed
14 and the usual fee or fees of the dentist.
15 (2) The signature of both the eligible claimant and the
16 dentist.
17 (3) Whether or not the claimant has paid the copayment
18 portion, if any.
19 (4) A certification in the dentist's signature box that
20 the dentist performed the dental service or services or that
21 the dental service or services were performed under his
22 direct supervision, and also that the dentist, or anyone
23 performing services under his direct supervision, is legally
24 qualified to perform the dental service or services in
25 question.
26 (5) A certification in the dentist's signature box that
27 the dentist agrees to accept 85% of his usual fee as payment
28 in full for any dental service any part of which is paid for
29 under the program.
30 (6) The dentist's Pennsylvania dental license number and
19850H0901B1032 - 8 -
1 his address.
2 (e) Effect of election by dentist.--The election by a
3 dentist to treat eligible claimants under the program shall not
4 in any way result in any alteration of the computation of the
5 dentist's usual fee under any other dental insurance program.
6 Section 8. Penalties.
7 (a) Criminal penalties.--Any person who submits a false or
8 fraudulent claim under this act, or who aids or abets another in
9 the submission of a false or fraudulent claim, or who is
10 eligible under a private, State or Federal program for dental
11 assistance and who claims or receives duplicative benefits under
12 this act or who otherwise violates any provisions of this act,
13 commits a misdemeanor of the second degree.
14 (b) Report to examining board.--Any dentist who has been
15 found guilty of violating this act shall be reported to the
16 State Dental Council and Examining Board for appropriate action.
17 (c) Repayment of gain.--Any dentist or recipient who is
18 found guilty of violating this act shall be required to repay
19 three times the material gain he received, plus interest, in
20 addition to any criminal penalty.
21 (d) Any person who has been found guilty of violating this
22 act shall be ineligible to participate in the program for a
23 period of five years from the date of conviction.
24 Section 9. Implementation of act.
25 Implementation of the provisions of this act shall provide
26 that a program be in place and that payment of benefits begin
27 within four months of the effective date of this act.
28 Section 10. Expiration.
29 This act expires three years from its effective date, unless
30 extended by statute.
19850H0901B1032 - 9 -
1 Section 11. Effective date.
2 This act shall take effect immediately.
D8L71WMB/19850H0901B1032 - 10 -