RS C.S.H.B. 2063 75(R) BILL ANALYSIS INSURANCE C.S.H.B. 2063 By: Van de Putte 4-16-97 Committee Report (Substituted) BACKGROUND Currently there are two significant problems for consumers in acquiring comprehensive dental care. First, 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. However, many benefit plans deny payment for the necessary anesthesia and hospitalization which may be necessary for these patients to receive care. The second problem is coverage for temporomandibular joint disorders. These disorders of the jaw can cause severe headaches, earaches, and muscle spasms. While a law passed in the 70th legislature required coverage for these types of disorders, additional clarification is necessary to update the insurance code. PURPOSE H.B. 2063 would mandate coverage by health benefit plans for diagnosis and treatment of temporomandibular joint disorders and would prohibit a health benefit plan from excluding from coverage of an individual with a diagnosis or condition that requires their dental care from being provided in a traditional dental office with traditional local anesthetic. RULEMAKING AUTHORITY It is the committee's opinion that this bill does not expressly grant any additional rulemaking authority to a state officer, department, agency or institution. SECTION BY SECTION ANALYSIS SECTION 1. - Amends Article 21.53A, Insurance Code, as follows: Art. 21.53A. - BENEFITS FOR CERTAIN BONE AND JOINT PROCEDURES Sec. 1. - DEFINITIONS - Defines "Health benefit plan." Sec. 2. - SCOPE OF ARTICLE - Lists types of benefit plans that this article does and does not apply to. Sec. 3.- REQUIRED BENEFIT FOR DIAGNOSIS AND TREATMENT AFFECTING TEMPROMANDIBULAR JOINT. (a) Changes term "policy" to "plan." Article states that coverage must be provided by these plans for diagnostic or surgical treatment for conditions affecting jaw and craniomandibular joint. (b) Each health benefit shall provide coverage for diagnosis or treatment made necessary as a result of an accident, trauma, congenital defect, developmental defect, or pathology. (c) Other provisions applicable to surgical treatment under the health benefit plan may be applied to benefits under this article. Sec. 4. - DENTAL BENEFITS - (a) This article does not require the provision or dental services unless they are already provided under the plan. (b) A health benefit plan may not exclude an enrollee who is unable to undergo dental treatment in an office setting or under local anesthesia due to a documented physical, mental, or medical reason. (c) Subsection (c) is removed. SECTION 2. - Effective Date of Act, September 1, 1997. Act applies to policies issued or enacted on or after January 1, 1998. SECTION 3. - Emergency Clause. COMPARISON OF ORIGINAL TO SUBSTITUTE C.S.H.B. 2063 incorporates the legislative council definition of "health benefit plan" to replace the original definition of "employee benefit plan." The new term specifically includes any health insurance plan regulatable by the State of Texas including Section 5.01(a) of the Medical Practice Act nonprofit health corporations and does not include plans for specific disease coverage, accidental death or dismemberment, wage recovery insurance, or supplemental liability insurance coverage, medicare, workers compensation, motor vehicle insurance medical payments, and a long-term care health insurance policy. C.S.H.B. 2063 then restructures the remaining provisions of H.B. 2063 and restores to the original language the requirement that the treatment covered be "medically" necessary, narrows the scope of coverage mandated for the medical and surgical treatment of the temporomandibular joint, and creates a new section for the mandate for coverage for those persons unable, for documented medical or physical or mental reasons, to receive dental treatment in a traditional setting.