HOUSE DOCKET, NO. 2356        FILED ON: 1/14/2009

HOUSE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 1034

The Commonwealth of Massachusetts

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In the Year Two Thousand Nine

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An Act relative to insurance coverage for craniofacial disorders..

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

SECTION 1.  Chapter 175 of the General Laws, as appearing  in the 2006 Official Edition, is hereby amended by inserting after section 47U the following section:-

Section 47V.  (a)  Any individual policy of accident and sickness insurance pursuant to section one hundred and eight and any group blanket policy of accident and sickness insurance issued pursuant to section one hundred and ten shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital defects, developmental deformities, trauma, tumors, infections or disease.  Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, including, but not limited to cleft lip, cleft palate, ectodermal dysplasia, dentinogenesis imperfect, amelogenesis imperfectal, and other maxillofacial abnormalities.  Coverage shall not include cosmetic surgery or for dental or orthodontic treatment unrelated to congenital defects, developmental deformities, trauma, tumors, infections or disease.  All coverage shall be subject to any deductible, cost-sharing, and policy or contract maximum provisions, provided that they are no more restrictive for such services than for any injury or sickness covered under the policy. 

SECTION 2.  Chapter 176A of the General Laws, as appearing  in the 2006 Official Edition, is hereby amended by inserting after section 8AA the following section:-

Section 8BB.  (a)  Any contract between a subscriber and the corporation under an individual or group hospital service plan delivered, issued or renewed in the commonwealth shall provide, as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage for medically necessary functional repair or restoration of craniofacial disorders to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital defects, developmental deformities, trauma, tumors, infections or disease.  Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, including, but not limited to cleft lip, cleft palate, ectodermal dysplasia, dentinogenesis imperfect, amelogenesis imperfectal, and other maxillofacial abnormalities.  Coverage shall not include cosmetic surgery or for dental or orthodontic treatment unrelated to congenital defects, developmental deformities, trauma, tumors, infections or disease.  All coverage shall be subject to any deductible, cost-sharing, and policy or contract maximum provisions, provided that they are no more restrictive for such services than for any injury or sickness covered under the policy. 

SECTION 3.  Chapter 176B of the General Laws, as appearing  in the 2006 Official Edition, is hereby amended by inserting after section 4Rthe following section:-

Section 4S.  (a)  Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed in the commonwealth shall provide, as benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage for medically necessary functional repair or restoration of craniofacial disorders to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital defects, developmental deformities, trauma, tumors, infections or disease.  Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities, including, but not limited to cleft lip, cleft palate, ectodermal dysplasia, dentinogenesis imperfect, amelogenesis imperfectal, and other maxillofacial abnormalities.  Coverage shall not include cosmetic surgery or for dental or orthodontic treatment unrelated to congenital defects, developmental deformities, trauma, tumors, infections or disease.  All coverage shall be subject to any deductible, cost-sharing, and policy or contract maximum provisions, provided that they are no more restrictive for such services than for any injury or sickness covered under the policy. 

SECTION 4.  Chapter 176G of the General Laws, as appearing  in the 2006 Official Edition, is hereby amended by striking out section 4 and inserting in place thereof  the following section:-

Section 4.  A health maintenance contract shall provide coverage for:

(a) pregnant women, infants and children as set forth in section 47C of chapter 175;

(b) cardiac rehabilitation as set forth in section 47D of chapter 175;

(c) prenatal care, childbirth and postpartum care as set forth in section 47F of chapter 175;

(d) cytologic screening and mammographic examination as set forth in section 47G of chapter 175;

(e) diagnosis and treatment of infertility as set forth in section 47H of chapter 175;

(f) services rendered by a certified registered nurse anesthetist or nurse practitioner as set forth in section 47Q of chapter 175, subject to the terms of a negotiated agreement between the health maintenance organization and the provider of health care services as set forth in section 47V of chapter 175; and

(g) medically necessary functional repair or restoration of craniofacial disorders to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital defects, developmental deformities, trauma, tumors, infections or disease.

The dependent coverage of any such policy shall also provide coverage for medically necessary early intervention services delivered by certified early intervention specialists, as defined in the early intervention operational standards by the department of public health and in accordance with applicable certification requirements. Such medically necessary services shall be provided by early intervention specialists who are working in early intervention programs certified by the department of public health, as provided in sections 1 and 2 of chapter 111G, for children from birth until their third birthday. Reimbursement of costs for such services shall be part of a basic benefits package offered by the insurer or a third party, with a maximum benefit of $5,200 per year per child and an aggregate benefit of $15,600 over the total enrollment period.