PRINTER'S NO. 1668
No. 1291 Session of 2000
INTRODUCED BY HART, GERLACH, EARLL, TILGHMAN, WHITE, KUKOVICH,
MADIGAN, COSTA, TOMLINSON, TARTAGLIONE, MUSTO AND SALVATORE,
FEBRUARY 9, 2000
REFERRED TO BANKING AND INSURANCE, FEBRUARY 9, 2000
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
17 incurred expenses or treatment not performed, at the expense
1 of the child's health.
2 (5) Mandatory insurance coverage for general anesthesia
3 for dental treatment is essential to ensure that all children
4 receive the dental treatment they need to maintain good
5 health.
6 The General Assembly of the Commonwealth of Pennsylvania
7 hereby enacts as follows:
8 Section 101. Short title.
9 This act shall be known and may be cited as the Access to
10 Dental Care Act.
11 Section 102. Definitions.
12 The following words and phrases when used in this act shall
13 have the meanings given to them in this section unless the
14 context clearly indicates otherwise:
15 "Associated medical costs." Hospitalization and related
16 medical expenses, such as the administration of general
17 anesthesia when dental treatment must be performed in a dental
18 office.
19 "Dental care." The diagnosis, treatment planning and
20 implementation of services directed at the prevention and
21 treatment of diseases, conditions and dysfunctions, except
22 temporal mandibular joint disorders, relating to the oral cavity
23 and its associated structures and their impact upon the human
24 body, or the implementation of professional dental care, which
25 includes diagnostic, preventive, therapeutic, restorative, oral
26 and maxillofacial, surgical, endodontic, prosthodontic,
27 orthodontic, periodontic and aesthetic or cosmetic services
28 provided to dental patients by a legally qualified dentist or
29 physician operating within the scope of the dentist's or
30 physician's training.
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1 "Eligible dental patient." Either of the following:
2 (1) An individual who is severely disabled mentally,
3 physically, developmentally, emotionally or behaviorally and
4 who is an extremely uncooperative, unmanageable, anxious,
5 fearful individual with respect to dental care or who is an
6 uncommunicative individual with dental needs deemed
7 sufficiently important that dental care cannot be deferred.
8 (2) A child 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 an individual's inability to maintain an
14 airway independently and to respond purposefully to physical
15 stimulation or verbal command.
16 "Health care facility." A facility providing clinically
17 related health services, including, but not limited to, a
18 general or special hospital, including psychiatric hospitals,
19 rehabilitation hospitals, ambulatory surgical facilities, long-
20 term care nursing facilities, cancer treatment centers using
21 radiation therapy on an ambulatory basis and inpatient drug and
22 alcohol treatment facilities, both profit and nonprofit and
23 including those operated by an agency or State or local
24 government. The term shall also include a hospice. The term
25 shall not include an office used primarily for the private or
26 group practice by health care practitioners where no reviewable
27 clinically related health service is offered, a facility
28 providing treatment solely on the basis of prayer or spiritual
29 means in accordance with the tenets of a church or religious
30 denomination or a facility conducted by a religious organization
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1 for the purpose of providing health care services exclusively to
2 clergy or other persons in a religious profession who are
3 members of the religious denominations conducting the facility.
4 "Health insurance policy." An individual or group health,
5 sickness or accident policy, subscriber contract or certificate
6 issued by an entity subject to this act or any of the following:
7 (1) The act of May 17, 1921 (P.L.682, No.284), known as The
8 Insurance Company Law of 1921.
9 (2) The act of December 29, 1972 (P.L.1701, No.364), known
10 as the Health Maintenance Organization Act.
11 (3) The act of December 14, 1992 (P.L.835, No.134), known as
12 the Fraternal Benefit Societies Code.
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 for the
21 Uniform Services (CHAMPUS) supplement, long-term care,
22 disability income, workers' compensation or automobile medical
23 payment.
24 Section 103. Nature of required coverage.
25 (a) Provisions for health insurance policies.--A health
26 insurance policy:
27 (1) Shall cover general anesthesia and associated
28 medical costs provided to an eligible dental patient.
29 (2) May require authorization of hospitalization for
30 dental care procedures in the same manner that prior
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1 authorization is required by the insurer for hospitalization
2 for other covered diseases or conditions.
3 (3) That provides accident and health insurance to a
4 resident of this Commonwealth shall provide coverage for
5 general anesthesia and associated medical costs derived by
6 its administration and billed by a dentist for an eligible
7 dental patient excluding dental care covered under the health
8 plan, regardless of whether the services are provided in a
9 health care facility or a dental office.
10 (4) Shall permit a guardian or parent of an eligible
11 dental patient to require that dental work and anesthesia be
12 performed in a health care facility regardless of the opinion
13 of the dentist.
14 (b) Coverage subject to annual deductibles or coinsurance
15 requirements.--The coverage required under this act shall be
16 subject to the annual deductibles or coinsurance requirements
17 imposed by an entity subject to this act for similar coverages
18 under the same health insurance policy or contract.
19 (c) Construction.--This act shall not be construed to
20 require coverage for dental care for which general anesthesia is
21 provided.
22 Section 104. Delivery of policy.
23 If a health insurance policy provides coverage or benefits to
24 a resident of this Commonwealth, it shall be deemed to be
25 delivered in this Commonwealth within the meaning of this act,
26 regardless of whether the health care insurer issuing or
27 delivering the policy is located within or outside this
28 Commonwealth.
29 Section 105. Repeals.
30 All acts and parts of acts are repealed insofar as they are
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1 inconsistent with this act.
2 Section 106. Applicability.
3 This act shall apply to all health insurance policies issued
4 under any group master policy or individual policy delivered or
5 issued for delivery on or after the effective date of this act
6 only to residents of this Commonwealth and to renewals of such
7 policies on or after the effective date of this act.
8 Section 107. Effective date.
9 This act shall take effect in 180 days.
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