SECTION 1. Chapter 32A of the General Laws is hereby amended by inserting after section 17O, as inserted by chapter 233 of the acts 2016, the following section:-

Section 17P. Any coverage offered by the commission to an active or retired employee of the commonwealth insured under the group insurance commission shall provide coverage for the hospital or ambulatory center charges and administration of general anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist for dental procedures performed on a covered person who is: (i) a child seven years of age or younger who is determined by a licensed dentist to be unable to receive needed dental treatment in an outpatient setting, and the provider treating the patient certifies that due to the patient’s age and the patient’s condition, hospitalization or general anesthesia in a hospital or ambulatory surgical center is required in order to perform significantly complex dental procedures safely and effectively; (ii) a child 12 years of age or younger with documented phobias or a documented mental illness, as determined by a physician or by a licensed mental health professional, whose dental needs are sufficiently complex and urgent that delaying or deferring treatment may result in infection or loss of teeth; for whom a successful result cannot be expected from dental care provider under local anesthesia; and for whom a superior result can be expected from dental care provided under general anesthesia; or (iii) a person who has exceptional medical circumstances or a development disability, as determined by a licensed physician which places the person at serious risk.

The coverage required by this section may be subject to prior authorization for general anesthesia and associated hospital or ambulatory surgical center charges for dental care in the same manner that prior authorization is required for these benefits in connection with other covered medical care.

The coverage required by this section may be restricted to dental care that is provided by: (i) fully accredited specialist in pediatric dentistry; (ii) a fully accredited specialist in oral and maxillofacial surgery; and (iii) a dentist to whom hospital privileges have been granted.

Nothing in this section shall require coverage for the dental procedures or other dental care for which general anesthesia is provided; and provided, that coverage shall be subject to annual deductible, co-payment, or co-insurance requirements, and any other general exclusions of a health insurance policy to the same extent as other medical services covered by the policy.

SECTION 2. Chapter 118E of the General Laws is hereby amended by inserting after section 10J, as inserted by chapter 233 of the acts 2016, the following section:-

Section 10K. The division shall provide coverage for the hospital or ambulatory center charges and administration of general anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist for dental procedures performed on a covered person who is: (i) a child seven years of age or younger who is determined by a licensed dentist to be unable to receive needed dental treatment in an outpatient setting, and the provider treating the patient certifies that due to the patient’s age and the patient’s condition, hospitalization or general anesthesia in a hospital or ambulatory surgical center is required in order to perform significantly complex dental procedures safely and effectively; (ii) a child 12 years of age or younger with documented phobias or a documented mental illness, as determined by a physician or by a licensed mental health professional, whose dental needs are sufficiently complex and urgent that delaying or deferring treatment may result in infection or loss of teeth; for whom a successful result cannot be expected from dental care provider under local anesthesia; and for whom a superior result can be expected from dental care provided under general anesthesia; or (iii) a person who has exceptional medical circumstances or a development disability, as determined by a licensed physician which places the person at serious risk.

SECTION 3. Chapter 175 of the General Laws is hereby amended by inserting after section 47II, as inserted by chapter 233 of the acts 2016, the following section:-

Section 47JJ. A policy, contract, agreement, plan or certificate of insurance issued, delivered or renewed within the commonwealth that provides medical expense coverage shall provide coverage for the hospital or ambulatory center charges and administration of general anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist for dental procedures performed on a covered person who is: (i) a child seven years of age or younger who is determined by a licensed dentist to be unable to receive needed dental treatment in an outpatient setting, and the provider treating the patient certifies that due to the patient’s age and the patient’s condition, hospitalization or general anesthesia in a hospital or ambulatory surgical center is required in order to perform significantly complex dental procedures safely and effectively; (ii) a child 12 years of age or younger with documented phobias or a documented mental illness, as determined by a physician or by a licensed mental health professional, whose dental needs are sufficiently complex and urgent that delaying or deferring treatment may result in infection or loss of teeth; for whom a successful result cannot be expected from dental care provider under local anesthesia; and for whom a superior result can be expected from dental care provided under general anesthesia; or (iii) a person who has exceptional medical circumstances or a development disability, as determined by a licensed physician which places the person at serious risk.

SECTION 4. Chapter 176A of the General Laws is hereby amended by inserting after section 8KK, as inserted by chapter 233 of the acts 2016, the following section:-

Section 8LL. A contract between a subscriber and the corporation under an individual or group hospital service plan that is delivered, issued or renewed within the commonwealth shall provide coverage for the hospital or ambulatory center charges and administration of general anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist for dental procedures performed on a covered person who is: (i) a child seven years of age or younger who is determined by a licensed dentist to be unable to receive needed dental treatment in an outpatient setting, and the provider treating the patient certifies that due to the patient’s age and the patient’s condition, hospitalization or general anesthesia in a hospital or ambulatory surgical center is required in order to perform significantly complex dental procedures safely and effectively; (ii) a child 12 years of age or younger with documented phobias or a documented mental illness, as determined by a physician or by a licensed mental health professional, whose dental needs are sufficiently complex and urgent that delaying or deferring treatment may result in infection or loss of teeth; for whom a successful result cannot be expected from dental care provider under local anesthesia; and for whom a superior result can be expected from dental care provided under general anesthesia; or (iii) a person who has exceptional medical circumstances or a development disability, as determined by a licensed physician which places the person at serious risk.

SECTION 5. Chapter 176B of the General Laws is hereby amended by inserting after section 4KK, as inserted by chapter 233 of the acts 2016, the following section:-

Section 4LL. A subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for the hospital or ambulatory center charges and administration of general anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist for dental procedures performed on a covered person who is: (i) a child seven years of age or younger who is determined by a licensed dentist to be unable to receive needed dental treatment in an outpatient setting, and the provider treating the patient certifies that due to the patient’s age and the patient’s condition, hospitalization or general anesthesia in a hospital or ambulatory surgical center is required in order to perform significantly complex dental procedures safely and effectively; (ii) a child 12 years of age or younger with documented phobias or a documented mental illness, as determined by a physician or by a licensed mental health professional, whose dental needs are sufficiently complex and urgent that delaying or deferring treatment may result in infection or loss of teeth; for whom a successful result cannot be expected from dental care provider under local anesthesia; and for whom a superior result can be expected from dental care provided under general anesthesia; or (iii) a person who has exceptional medical circumstances or a development disability, as determined by a licensed physician which places the person at serious risk.

SECTION 6. Chapter 176G of the General Laws is hereby amended by inserting after section 4CC, as inserted by chapter 233 of the acts 2016, the following section:-

Section 4DD. An individual or group health maintenance contract shall provide coverage for a dental procedure that is related to or resulting from a medical condition for the hospital or ambulatory center charges and administration of general anesthesia administered by a licensed anesthesiologist or certified registered nurse anesthetist for dental procedures performed on a covered person who is: (i) a child seven years of age or younger who is determined by a licensed dentist to be unable to receive needed dental treatment in an outpatient setting, and the provider treating the patient certifies that due to the patient’s age and the patient’s condition, hospitalization or general anesthesia in a hospital or ambulatory surgical center is required in order to perform significantly complex dental procedures safely and effectively; (ii) a child 12 years of age or younger with documented phobias or a documented mental illness, as determined by a physician or by a licensed mental health professional, whose dental needs are sufficiently complex and urgent that delaying or deferring treatment may result in infection or loss of teeth; for whom a successful result cannot be expected from dental care provider under local anesthesia; and for whom a superior result can be expected from dental care provided under general anesthesia; or (iii) a person who has exceptional medical circumstances or a development disability, as determined by a licensed physician which places the person at serious risk.

SECTION 7. This act shall apply to all health insurance policies offered, issued, or renewed on or after the effective date of this act.

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Bill H.1093