HBA-DMH C.S.S.B. 1411 77(R)    BILL ANALYSIS


Office of House Bill AnalysisC.S.S.B. 1411
By: Moncrief
Public Health
5/5/2001
Committee Report (Substituted)



BACKGROUND AND PURPOSE 

The House Committee on General Investigating conducted an interim
investigation on the excessive use of stainless steel crowns and other
aggressive dental procedures by certain providers in the Medicaid program.
This investigation found some evidence of fraud in the Texas Health Steps
Dental Services Program.  Various procedures and certain billing codes
offer providers the chance to defraud the dental program.  The committee
recommended various changes to help eliminate abuse of the system, and to
improve the quality of services and care offered by the program.  C.S.S.B.
1411 incorporates the recommendations of the House Committee on General
Investigating to reduce fraud in the program. 

RULEMAKING AUTHORITY

It is the opinion of the Office of House Bill Analysis that rulemaking
authority is expressly delegated to the Health and Human Services
Commission in SECTION 1 (Section 32.053, Human Resources Code) of this
bill. 

ANALYSIS

C.S.S.B. 1411 amends the Human Resources Code to prohibit a dental service
or product from being provided under Medicaid unless there is a dental
necessity for the service or product. The bill requires the Health and
Human Services Commission (HHSC), in providing dental services under the
medical assistance program (Medicaid), to: 

 _ensure that a stainless steel crown is not used as a preventive measure;

 _require a dentist participating in Medicaid to document, through x-rays
or other methods established by HHSC rule, the dental necessity for a
stainless steel crown before it is applied; 

 _require a dentist participating in Medicaid to comply with a minimum
standard of documentation and recordkeeping for each of the dentist's
patients; 

 _establish such a minimum standard in cooperation with the State Board of
Dental Examiners; 

 _replace the 15-point system used for determining the dental necessity for
hospitalization and general anesthesia with a more objective and
comprehensive system developed by HHSC; and 

 _take all necessary action to eliminate unlawful acts in the provision of
dental services under Medicaid. 

The bill requires HHSC, in setting reimbursement rates, to reduce the
hospitalization fee and eliminate the nutritional consultation fee and
redistribute amounts made available by such actions to other commonly
billed dental services for which adequate accountability measures exist.
The bill requires HHSC to set the reimbursement rate for a stainless steel
crown at an amount equal to the reimbursement rate for an amalgam or resin
filling.  The bill requires HHSC to provide for reimbursement of a behavior
management fee only under certain conditions and to redistribute amounts
made available through the limitation of the behavior management fee to
other commonly billed dental services for which adequate accountability
measures exits.  

EFFECTIVE DATE

On passage, or if the Act does not receive the necessary vote, the Act
takes effect September 1, 2001. 

COMPARISON OF ORIGINAL TO SUBSTITUTE

C.S.S.B. 1411 differs from the original by requiring the  Health and Human
Services Commission  to set the reimbursement rate for a stainless steel
crown at an amount equal to the  reimbursement rate for an amalgam or resin
filling.