Amendment #14 to H4643

Ensuring treatment for genetic craniofacial conditions

Mr. Fernandes of Falmouth moves to amend the amendment by adding the following eight sections:

"SECTION XX. Chapter 32A of the General Laws is hereby amended by inserting after section 17N as appearing in the 2014 Official Edition, the following section:-

Section 17O. 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 medically necessary functional repair or restoration of craniofacial disorders, with the exception of coverage for cleft lip and cleft palate which is prescribed elsewhere in the General Laws, to improve the function of, or to approximate the normal appearance or any abnormal structures caused by congenital disease of anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly. Including, but not limited to, ectodermal dysplasia, dentinogenesis imperfecta, amelogenesis imperfecta. Coverage shall not include cosmetic surgery or for dental or orthodontic treatment unrelated to congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the commission.

SECTION XX. Chapter 118E of the General Laws is hereby amended by inserting after section 10I, inserted by section 105 of chapter 46 of the acts of 2015, the following section:-

Section 10J. The division shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed elsewhere in the General Laws, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly, including ectodermal dysplasia, dentinogenesis imperfecta, and amelogenesis imperfecta. Coverage shall not include cosmetic surgery or for dental or orthodontic treatment unrelated to congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the division.

SECTION XX. Chapter 175 of the General Laws is hereby amended by inserting after section 47GG, as appearing in the 2014 Official Edition, the following section:-

Section 47HH. The following shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed elsewhere in the General Laws, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly, including ectodermal dysplasia, dentinogenesis imperfecta, and amelogenesis imperfecta. Coverage shall not include cosmetic surgery or dental or orthodontic treatment unrelated to congenital disease or anomaly.: (i) any policy of accident and sickness insurance, as described in section 108, which provides hospital expense and surgical expense insurance and which is delivered, issued or subsequently renewed by agreement between the insurer and policyholder in the commonwealth; (ii) any blanket or general policy of insurance described in subdivision (A), (C) or (D) of section 110 which provides hospital expense and surgical expense insurance and which is delivered, issued or subsequently renewed by agreement between the insurer and the policyholder in or outside of the commonwealth; or (iii) any employees’ health and welfare fund which provides hospital expense and surgical expense benefits and which is delivered, issued or renewed to any person or group of persons in the commonwealth. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION XX. Chapter 176A of the General Laws is hereby amended by inserting after section 8II, as so appearing, the following section:-

Section 8JJ. Any contract between a subscriber and the corporation under an individual or group hospital service plan which is delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed elsewhere in the General Laws, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly, including, ectodermal dysplasia, dentinogenesis imperfecta,and  amelogenesis imperfecta. Coverage shall not include cosmetic surgery or dental or orthodontic treatment unrelated to congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION XX. Chapter 176B of the General Laws is hereby amended by inserting after section 4II, as so appearing, the following section:-

Section 4JJ. Any subscription certificate under an individual or group medical service agreement delivered, issued or renewed within the commonwealth shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed elsewhere in the General Laws, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by disease or anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly, including, ectodermal dysplasia, dentinogenesis imperfecta, and amelogenesis imperfecta. Coverage shall not include cosmetic surgery or dental or orthodontic treatment unrelated to congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION XX. Chapter 176G of the General Laws, as so appearing, is hereby amended by inserting after section 4AA, as so appearing, the following section:-

Section 4BB. Any individual or group health maintenance contract shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed elsewhere in the General Laws, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly, including, ectodermal dysplasia, dentinogenesis imperfecta, and amelogenesis imperfecta. Coverage shall not include cosmetic surgery or dental or orthodontic treatment unrelated to congenital disease or anomaly. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION XX. Chapter 176I of the General Laws, as so appearing, is hereby amended by inserting after section,12, as so appearing, the following section:-

Section 13. An organization entering into a preferred provider contract shall provide coverage for medically necessary functional repair or restoration of craniofacial disorders; with the exception of coverage for cleft lip and cleft palate which is prescribed elsewhere in the General Laws, to improve the function of, or to approximate the normal appearance of any abnormal structures caused by congenital disease or anomaly. Coverage under this section shall include the necessary care and treatment of medically diagnosed congenital disease or anomaly, including, ectodermal dysplasia, dentinogenesis imperfecta, and amelogenesis imperfecta. Coverage shall not include cosmetic surgery or dental or orthodontic treatment unrelated to congenital defects, developmental deformities, trauma, tumors, infections or disease. The benefits in this section shall not be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefit provided by the insurer.

SECTION XX. This act shall apply to all policies, contracts and certificates of health insurance subject to chapters 32A, 118E, 175, 176A, 176B, 176G and 176I, of the General Laws, as so appearing, issued or renewed, except any entity to the extent it offers a policy, certificate or contract that provides coverage for dental care services or vision care services."

Additional co-sponsor(s) added to Amendment #14 to H4643

Ensuring treatment for genetic craniofacial conditions