1-1 By: Moncrief S.B. No. 1411 1-2 (In the Senate - Filed March 8, 2001; March 13, 2001, read 1-3 first time and referred to Committee on Health and Human Services; 1-4 April 11, 2001, reported adversely, with favorable Committee 1-5 Substitute by the following vote: Yeas 5, Nays 0; April 11, 2001, 1-6 sent to printer.) 1-7 COMMITTEE SUBSTITUTE FOR S.B. No. 1411 By: Moncrief 1-8 A BILL TO BE ENTITLED 1-9 AN ACT 1-10 relating to dental services provided under the medical assistance 1-11 program. 1-12 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-13 SECTION 1. Subchapter B, Chapter 32, Human Resources Code, 1-14 is amended by adding Section 32.053 to read as follows: 1-15 Sec. 32.053. DENTAL SERVICES. (a) For purposes of this 1-16 section, the "dental necessity" for a dental service or product is 1-17 defined as the circumstances under which a prudent dentist, acting 1-18 in accordance with generally accepted practices of the professional 1-19 dental community and within the parameters of care of the American 1-20 Dental Association and within the quality assurance criteria of the 1-21 American Academy of Pediatric Dentistry, as applicable, would 1-22 provide the service or product to a patient to diagnose, prevent, 1-23 or treat orofacial pain, infection, disease, dysfunction, or 1-24 disfiguration. 1-25 (b) A dental service or product may not be provided under 1-26 the medical assistance program unless there is a dental necessity 1-27 for the service or product. 1-28 (c) In providing dental services under the medical 1-29 assistance program, the department shall: 1-30 (1) ensure that a stainless steel crown is not used as 1-31 a preventive measure; 1-32 (2) require a dentist participating in the medical 1-33 assistance program to document, through x-rays or other methods 1-34 established by department rule, the dental necessity for a 1-35 stainless steel crown before the crown is applied; 1-36 (3) require a dentist participating in the medical 1-37 assistance program to comply with a minimum standard of 1-38 documentation and recordkeeping for each of the dentist's patients; 1-39 (4) replace the 15-point system used for determining 1-40 the dental necessity for hospitalization and general anesthesia 1-41 with a more objective and comprehensive system developed by the 1-42 department; and 1-43 (5) take all necessary action to eliminate unlawful 1-44 acts described by Section 36.002 in the provision of dental 1-45 services under the medical assistance program, including: 1-46 (A) aggressively investigating and prosecuting 1-47 any dentist who abuses the system for reimbursement under the 1-48 medical assistance program; and 1-49 (B) conducting targeted audits of dentists whose 1-50 billing activities under the medical assistance program are 1-51 excessive or otherwise inconsistent with the billing activities of 1-52 other similarly situated dentists. 1-53 (d) In setting reimbursement rates for dental services under 1-54 the medical assistance program, the department shall: 1-55 (1) reduce the amount of the hospitalization fee in 1-56 effect on December 1, 2000, and redistribute amounts made available 1-57 through reduction of that fee to other commonly billed dental 1-58 services for which adequate accountability measures exist; 1-59 (2) eliminate the nutritional consultation fee and 1-60 redistribute amounts made available through elimination of that fee 1-61 to other commonly billed dental services for which adequate 1-62 accountability measures exist; 1-63 (3) provide for reimbursement of a behavior management 1-64 fee only if: 2-1 (A) the patient receiving dental treatment has 2-2 been previously diagnosed with mental retardation or a mental 2-3 disability or disorder, and extraordinary behavior management 2-4 techniques are necessary for therapeutic dental treatment because 2-5 of the patient's uncooperative behavior; and 2-6 (B) the dentist includes in the patient's 2-7 records and on the claim form for reimbursement a narrative 2-8 description of: 2-9 (i) the specific behavior problem 2-10 demonstrated by the patient that required the use of behavior 2-11 management techniques; 2-12 (ii) the dentist's initial efforts to 2-13 manage the patient's behavior through routine behavior management 2-14 techniques; and 2-15 (iii) the dentist's extraordinary behavior 2-16 management techniques subsequently required to manage the patient's 2-17 behavior; and 2-18 (4) redistribute amounts made available through 2-19 limitation of the behavior management fee under Subdivision (3) to 2-20 other commonly billed dental services for which adequate 2-21 accountability measures exist. 2-22 (e) The department shall develop the minimum standard 2-23 described by Subsection (c)(3) in cooperation with the State Board 2-24 of Dental Examiners. 2-25 SECTION 2. If before implementing any provision of this Act 2-26 a state agency determines that a waiver or authorization from a 2-27 federal agency is necessary for implementation of that provision, 2-28 the agency affected by the provision shall request the waiver or 2-29 authorization and may delay implementing that provision until the 2-30 waiver or authorization is granted. 2-31 SECTION 3. This Act takes effect immediately if it receives 2-32 a vote of two-thirds of all the members elected to each house, as 2-33 provided by Section 39, Article III, Texas Constitution. If this 2-34 Act does not receive the vote necessary for immediate effect, this 2-35 Act takes effect September 1, 2001. 2-36 * * * * *