SRC-JFA H.B. 2063 75(R) BILL ANALYSIS Senate Research Center H.B. 2063 By: Van de Putte (Cain) Economic Development 5-14-97 Engrossed DIGEST Currently, certain dental patients have conditions which require that they receive anesthesia or are hospitalized in order to receive dental treatment. These patients would include very small children who need extensive care and persons with mental or physical handicaps. Many benefit plans deny payment for the necessary anesthesia and hospitalization which may be necessary for these patients to receive care. This bill would prohibit a health benefit plan from excluding from coverage under the plan an individual who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the individual's physician or the dentist providing the dental care. Additionally, temporomandibular joint disorders can cause severe headaches, earaches, and muscle spasms. While an act passed in the 70th Legislature required coverage for such disorders, additional clarification may be necessary to update the Insurance Code. This bill would mandate coverage by health benefit plans for diagnosis and treatment of temporomandibular joint disorders. PURPOSE As proposed, H.B. 2063 prohibits a health benefit plan from excluding from coverage under the plan an individual who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason as determined by the individual's physician or the dentist providing the dental care. Additionally, this bill mandates coverage by health benefit plans for diagnosis and treatment of temporomandibular joint disorders. RULEMAKING AUTHORITY This bill does not grant any additional rulemaking authority to a state officer, institution, or agency. SECTION BY SECTION ANALYSIS SECTION 1. Amends Article 21.53A, Insurance Code, as follows: Sec. 1. DEFINITION. Defines "health benefit plan." Makes a conforming change. Sec. 2. SCOPE OF ARTICLE. Sets forth the group health plans that this article applies to in regard to benefits for certain bone and joint procedures. Sets forth the group health plans that this article does not apply to. Deletes existing definition of "health insurance policy." Sec. 3. REQUIRED BENEFIT FOR DIAGNOSIS AND TREATMENT AFFECTING TEMPOROMANDIBULAR JOINT. Requires each health benefit plan, rather than insurance policy, delivered or issued for delivery in this state that provides benefits for the medically necessary diagnostic or, rather than and/or, surgical treatment of skeletal joints to provide, rather than include, comparable coverage as provided by this article, rather than benefits, for the medically necessary diagnostic or surgical treatment of conditions affecting the temporomandibular, rather than temporomandibular jaw or craniomandibular, joint. Provides that for purposes of this section, the temporomandibular joint includes the jaw and the craniomandibular joint. Requires each health benefit plan to provide coverage under this article for diagnosis or surgical treatment medically necessary as a result of an accident; a trauma; a congenital defect; a developmental defect; or a pathology. Authorizes all other provisions, rather than policy provisions, generally applicable to surgical treatment under the health benefit plan to be applied to the benefits required under this article. Makes conforming changes. Sec. 4. DENTAL SERVICES. Prohibits a health benefit plan from excluding from coverage under the plan an individual who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or health reason as determined by the individual's physician or the dentist providing the dental care. Deletes existing Subsection (e). Makes conforming changes. SECTION 2. Effective date: September 1, 1997. Makes application of this Act prospective to January 1, 1998. SECTION 3. Emergency clause.