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S1338.......................................by COMMERCE AND HUMAN RESOURCES
DENTAL PROCEDURES - Adds to and amends existing law to provide for health
benefit plan and health care contract coverage of certain anesthesia and
hospital charges for dental procedures.
01/30 Senate intro - 1st rdg - to printing
01/31 Rpt prt - to Com/HuRes
|||| LEGISLATURE OF THE STATE OF IDAHO ||||
Fifty-sixth Legislature Second Regular Session - 2002
IN THE SENATE
SENATE BILL NO. 1338
BY COMMERCE AND HUMAN RESOURCES COMMITTEE
1 AN ACT
2 RELATING TO INSURANCE; AMENDING CHAPTER 21, TITLE 41, IDAHO CODE, BY THE ADDI-
3 TION OF A NEW SECTION 41-2147, IDAHO CODE, TO PROVIDE FOR HEALTH BENEFIT
4 PLAN COVERAGE OF CERTAIN ANESTHESIA AND HOSPITAL CHARGES FOR DENTAL PROCE-
5 DURES AND TO DEFINE "HEALTH BENEFIT PLAN"; AMENDING CHAPTER 22, TITLE 41,
6 IDAHO CODE, BY THE ADDITION OF A NEW SECTION 41-2224, IDAHO CODE, TO PRO-
7 VIDE FOR HEALTH BENEFIT PLAN COVERAGE OF CERTAIN ANESTHESIA AND HOSPITAL
8 CHARGES FOR DENTAL PROCEDURES AND TO DEFINE "HEALTH BENEFIT PLAN"; AMEND-
9 ING SECTION 41-3903, IDAHO CODE, TO FURTHER DEFINE "BASIC HEALTH CARE SER-
10 VICES"; AND AMENDING CHAPTER 39, TITLE 41, IDAHO CODE, BY THE ADDITION OF
11 A NEW SECTION 41-3933, IDAHO CODE, TO PROVIDE FOR HEALTH CARE CONTRACT
12 COVERAGE OF CERTAIN ANESTHESIA AND HOSPITAL CHARGES FOR DENTAL PROCEDURES.
13 Be It Enacted by the Legislature of the State of Idaho:
14 SECTION 1. That Chapter 21, Title 41, Idaho Code, be, and the same is
15 hereby amended by the addition thereto of a NEW SECTION, to be known and des-
16 ignated as Section 41-2147, Idaho Code, and to read as follows:
17 41-2147. ANESTHESIA AND HOSPITAL CHARGES FOR DENTAL PROCEDURES. (1) A
18 health benefit plan subject to the provisions of this chapter shall provide
19 coverage for payment of anesthesia and hospital or facility charges for ser-
20 vices performed in a hospital or outpatient surgery center in connection with
21 dental procedures for:
22 (a) Children ten (10) years of age or younger; and
23 (b) Persons who have a developmental disability, as defined in section
24 66-402, Idaho Code.
25 (2) The same deductibles, coinsurance, network requirements, medical
26 necessity provisions, and other limitations that apply to physical illness
27 benefits under the health benefit plan shall apply to coverage for anesthesia
28 and hospital or facility charges required to be covered under this section.
29 (3) As used in this section, "health benefit plan" means any hospital or
30 medical policy or certificate, or any health maintenance organization sub-
31 scriber contract. "Health benefit plan" does not include: a policy or certifi-
32 cate of insurance for a specific disease; hospital confinement indemnity;
33 accident-only, credit, dental, vision, medicare supplement, long-term care or
34 disability income insurance; coverage for student health benefits only; cover-
35 age issued as a supplement to liability insurance; worker's compensation or
36 similar insurance; automobile medical payment insurance; or nonrenewable
37 short-term coverage issued for a period of twelve (12) months or less.
38 SECTION 2. That Chapter 22, Title 41, Idaho Code, be, and the same is
39 hereby amended by the addition thereto of a NEW SECTION, to be known and des-
40 ignated as Section 41-2224, Idaho Code, and to read as follows:
41 41-2224. ANESTHESIA AND HOSPITAL CHARGES FOR DENTAL PROCEDURES. (1) A
2
1 health benefit plan subject to the provisions of this chapter shall provide
2 coverage for payment of anesthesia and hospital or facility charges for ser-
3 vices performed in a hospital or outpatient surgery center in connection with
4 dental procedures for:
5 (a) Children ten (10) years of age or younger; and
6 (b) Persons who have a developmental disability, as defined in section
7 66-402, Idaho Code.
8 (2) The same deductibles, coinsurance, network requirements, medical
9 necessity provisions, and other limitations that apply to physical illness
10 benefits under the health benefit plan shall apply to coverage for anesthesia
11 and hospital or facility charges required to be covered under this section.
12 (3) As used in this section, "health benefit plan" means any group hospi-
13 tal or medical policy or certificate, or any group health maintenance organi-
14 zation subscriber contract. "Health benefit plan" does not include: a policy
15 or certificate of insurance for a specific disease; hospital confinement
16 indemnity; accident-only, credit, dental, vision, medicare supplement, long-
17 term care or disability income insurance; coverage for student health benefits
18 only; coverage issued as a supplement to liability insurance; worker's compen-
19 sation or similar insurance; automobile medical payment insurance; or non-
20 renewable short-term coverage issued for a period of twelve (12) months or
21 less.
22 SECTION 3. That Section 41-3903, Idaho Code, be, and the same is hereby
23 amended to read as follows:
24 41-3903. DEFINITIONS. (1) "Basic health care services" means the follow-
25 ing services: preventive care, emergency care, inpatient and outpatient hospi-
26 tal and physician care, hospital-based rehabilitation treatment, diagnostic
27 laboratory and diagnostic and therapeutic radiological services. Except as
28 provided in section 41-3933, Idaho Code, iIt does not include mental health
29 services or services for alcohol or drug abuse, dental or vision services or
30 long-term rehabilitation treatment.
31 (2) "Coinsurance" means a percentage amount a member is responsible to
32 pay out-of-pocket for health care services after satisfaction of any applica-
33 ble deductibles or copayments, or both.
34 (3) "Copayment" means an amount a member must pay to a provider in pay-
35 ment for a specific health care service which is not fully prepaid.
36 (4) "Deductible" means the amount of expense a member must first incur
37 before the managed care organization begins payment for covered services.
38 (5) "Director" means the director of the department of insurance of the
39 state of Idaho.
40 (6) "Emergency facility" means any hospital or other facility where emer-
41 gency services are provided to a member including, but not limited to, a
42 physician's office.
43 (7) "Emergency services" means those health care services that are pro-
44 vided in a hospital or other emergency facility after the sudden onset of a
45 medical condition that manifests itself by symptoms of sufficient severity
46 including, but not limited to, severe pain, that the absence of immediate med-
47 ical attention could reasonably be expected by a prudent person who possesses
48 an average knowledge of health and medicine, to result in:
49 (a) Placing the patient's health in serious jeopardy;
50 (b) Serious impairment to bodily functions; or
51 (c) Serious dysfunction of any bodily organ or part.
52 (8) "Employer" means any person, firm, corporation, partnership or asso-
53 ciation.
3
1 (9) "Enrollee" means a person who either individually or through a group
2 has entered into a contract for services under a managed care plan.
3 (10) "General managed care plan" means a managed care plan which provides
4 directly or arranges to provide, at a minimum, basic health care services. A
5 general managed care plan shall include basic health care services.
6 (11) "Health care contract" means a contract entered into by a managed
7 care organization and an enrollee.
8 (12) "Health care services" means those services offered or provided by
9 health care facilities and health care providers relating to the prevention,
10 cure or treatment of illness, injury or disease.
11 (13) "Limited managed care plan" means a managed care plan which provides
12 dental care services, vision care services, mental health services, substance
13 abuse services, pharmaceutical services, podiatric care services or such other
14 services as the director may establish by rule to be limited health care ser-
15 vices. Limited health care services shall not include hospital, medical, sur-
16 gical or emergency services except as those services are provided incident to
17 limited health care services.
18 (14) "Managed care organization" means a public or private person or orga-
19 nization which offers a managed care plan. Unless otherwise specifically
20 stated, the provisions of this chapter shall apply to any person or organiza-
21 tion offering a managed care plan, whether or not a certificate of authority
22 to offer the plan is required under this chapter.
23 (15) "Managed care plan" means a contract of coverage given to an individ-
24 ual, family or group of covered individuals pursuant to which a member is
25 entitled to receive a defined set of health care benefits through an organized
26 system of health care providers in exchange for defined consideration and
27 which requires the member to use, or creates financial incentives for the mem-
28 ber to use, health care providers owned, managed, employed by or under con-
29 tract with the managed care organization.
30 (16) "Member" means a policyholder, enrollee or other individual partici-
31 pating in a managed care plan.
32 (17) "Person" means any natural or artificial person including, but not
33 limited to, individuals, partnerships, associations, corporations or other
34 legally recognized entities.
35 (18) "Provider" means any physician, hospital, or other person licensed or
36 otherwise authorized to furnish health care services.
37 (19) "Utilization management program" means a system of reviewing the med-
38 ical necessity, appropriateness, or quality of health care services and sup-
39 plies provided under a managed care plan using specified guidelines. Such a
40 system may include, but is not limited to, preadmission certification, the
41 application of practice guidelines, continued stay review, discharge planning,
42 preauthorization of ambulatory procedures and retrospective review.
43 SECTION 4. That Chapter 39, Title 41, Idaho Code, be, and the same is
44 hereby amended by the addition thereto of a NEW SECTION, to be known and des-
45 ignated as Section 41-3933, Idaho Code, and to read as follows:
46 41-3933. ANESTHESIA AND HOSPITAL CHARGES FOR DENTAL PROCEDURES. (1) A
47 health care contract which provides basic health care services subject to the
48 provisions of this chapter shall provide coverage for payment of anesthesia
49 and hospital or facility charges for services performed in a hospital or out-
50 patient surgery center in connection with dental procedures for:
51 (a) Children ten (10) years of age or younger; and
52 (b) Persons who have a developmental disability, as defined in section
53 66-402, Idaho Code.
4
1 (2) The same deductibles, coinsurance, network requirements, medical
2 necessity provisions, and other limitations that apply to physical illness
3 benefits under the health care contract shall apply to coverage for anesthesia
4 and hospital or facility charges required to be covered under this section.
STATEMENT OF PURPOSE
RS 11587C2
This bill requires health benefit plans in Idaho to provide
coverage for necessary general anesthesia and associated charges
when dental procedures must be performed on young children and
the developmentally disabled in hospital or outpatient surgical
care settings. It would ensure that dental procedures for
special needs patients be performed safely and effectively
without using high-risk procedures.
FISCAL IMPACT
There would be no impact to the state general fund.
Contact
Name: Victoria Paulson, Idaho State Dental Association
Phone: 208-659-2248
Rep. Hilde Kellogg
STATEMENT OF PURPOSE/FISCAL NOTE S 1338