BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: SB 630
S
AUTHOR: Steinberg
B
AMENDED: As Introduced
HEARING DATE:
April 15, 2009 6
CONSULTANT:
3
Tadeo
0
SUBJECT
Health care coverage: reconstructive surgery: dental and
orthodontic services
SUMMARY
Provides that health care service plans and health insurers
are required by law to provide dental or orthodontic
services, when related to and medically necessary to
provide or complete reconstructive surgery.
CHANGES TO EXISTING LAW
Existing law:
Existing law provides for the regulation of health care
service plans (health plans) by the Department of Managed
Health Care (DMHC) and for the regulation of health
insurers by the Department of Insurance (CDI). Health
plans and insurers are required by law to cover various
health care services, including basic health care services,
such as physician services, hospital inpatient and
ambulatory care services, diagnostic laboratory services,
preventive health services, emergency health care services,
and hospice care.
Existing law allows health plans and insurers, through
"utilization review," to deny, modify, or delay coverage
for a particular benefit or service, due to a finding that
Continued---
STAFF ANALYSIS OF SENATE BILL SB 630 (Steinberg)Page 2
the benefit or service is not medically necessary.
Existing law also establishes an independent medical review
process for third-party review of a health plan's or
insurer's decision to deny a benefit or service due to such
findings.
Existing law requires health plans and insurers to provide
coverage for reconstructive surgery, including surgeries to
correct or repair congenital defects and developmental
abnormalities, such as cleft lip, cleft palate, and other
craniofacial abnormalities. Existing law allows health
plans and health insurers to apply specific prior
authorization and utilization review procedures to requests
for such surgeries.
Existing law defines reconstructive surgery as surgery
performed to correct or repair abnormal structures of the
body caused by congenital defects, developmental
abnormalities, trauma, infection, tumors, or disease to do
either of the following:
(1) To improve function; (2) To create a normal appearance,
to the extent possible.
Additionally, existing law requires that health plans and
health insurers offer coverage for certain benefits and
services, such as orthotic and prosthetic devices,
alcoholism treatment, and acupuncture services; meaning
that they must provide subscribers the option to purchase
the benefit.
This bill:
This bill provides that health care service plans and
health insurers are required by law to provide dental or
orthodontic services, when related to and medically
necessary to provide or complete reconstructive surgery.
This bill states that the legislative intent of the bill is
to clarify and confirm that any dental or orthodontic
services, when related to and medically necessary to
provide or complete reconstructive surgery, are services
that are required by current law.
FISCAL IMPACT
Unknown.
STAFF ANALYSIS OF SENATE BILL SB 630 (Steinberg)Page 3
BACKGROUND AND DISCUSSION
The author states that this bill seeks to clarify the
existing reconstructive surgery mandate by explicitly
including dental and orthodontic services that must be
covered for reconstructive surgery purposes.
According to the author, when patients undergo
reconstructive surgery to correct congenital defects or
major injuries due to accidents, surgical teams often
include both medical and dental specialists. When children
are born with cleft palates, reconstructive surgery is
performed by a team of medical specialists that includes
orthodontic care to address extra teeth, missing teeth, or
extremely misplaced and misshapen teeth and jaws. Although
children do not receive this orthodontic care for cosmetic
reasons, it is often not considered a medical benefit for
the purposes of completing cleft palate procedures. These
children need orthodontics for medical reasons, but do not
have coverage unless they have separate dental insurance,
which may not fully cover the expensive orthodontic
procedures necessary to treat cleft palate repairs.
The author states that the language for this bill was
provided through technical assistance from DMHC after a
similar measure, SB 1634 (Steinberg) was vetoed last year.
Cleft palate
Cleft palate is the common term for a birth defect which
can include cleft palate, cleft lip, or other craniofacial
anomalies. A cleft palate is an opening in the roof of the
mouth in which the two sides of the palate did not fuse, or
join together, as an unborn baby was developing. A cleft
lip is a separation of the two sides of the lip. The
separation often includes the bones of the upper jaw and/or
upper gum. Because the lip and the palate develop
separately, it is possible for the child to have a cleft
lip, a cleft palate, or both cleft lip and cleft palate, or
other craniofacial anomalies, caused by the condition,
which can vary.
According to the California Birth Defects Monitoring
Program, this condition is one of the most common birth
defects in California, with nearly 700 cases reported in
the state each year. Of these, approximately 300 cases per
STAFF ANALYSIS OF SENATE BILL SB 630 (Steinberg)Page 4
year are children who have health insurance coverage
arrangements that would be subject to this bill.
A child born with a cleft palate frequently requires
several different types of services, such as surgery,
dental and orthodontic care, and speech therapy, all of
which need to be provided in a coordinated manner over a
period of years. This coordinated care is provided by
interdisciplinary cleft palate and/or craniofacial teams
comprised of professionals from a variety of health care
disciplines. A child born with a cleft palate can also
have associated problems with body functions which include
breathing, skeletal growth and development, hearing, speech
and language ability, and learning difficulties. Social
integration problems, due to having a severe chronic
condition, in general, and the effects of disfigurement,
also exist, especially among school age children.
Health plans' coverage of dental and orthodontic services
Health care service plans regulated by the DMHC and health
insurance products regulated by the CDI are required to
provide coverage for reconstructive surgery, including
surgeries to correct or repair congenital defects and
developmental abnormalities, such as oral clefts. However,
orthodontic procedures for oral cleft repair are not
explicitly included as covered services in the language of
the reconstructive surgery statute.
According to the California Health Benefits Review Program
(CHBRP) analysis of SB 1634, although health insurance does
not normally cover dental or orthodontic procedures, they
may be required to complete reconstructive surgery. For
example, dental or orthodontic procedures may be needed for
teeth damaged in an automobile accident or an extraction
required for cancer treatment.
California is one of fourteen states that mandate health
benefits for oral cleft repair. Several of these states,
including Connecticut, Florida, Indiana, Minnesota, South
Carolina, and Virginia, explicitly include orthodontic
procedures as part of the mandated oral cleft repair health
benefit. According to the CHBRP analysis of SB 1634, DMHC
considers dental and orthodontic procedures part of the
oral cleft reconstructive surgery, if the procedures are
deemed medically necessary.
STAFF ANALYSIS OF SENATE BILL SB 630 (Steinberg)Page 5
Prior legislation
SB 1634 (Steinberg, 2008) would have required health care
service plans and health insurers to provide coverage for
orthodontic services deemed necessary for medical reasons
for cleft palate procedures identified by the Cleft Palate
Foundation for cleft palate repair procedures, subject to
prior authorization and utilization review procedures that
apply to reconstructive surgery, generally. This bill was
vetoed by the Governor.
In his veto message, the Governor stated that the bill,
while well-intentioned, would serve to increase the overall
cost of health care associated with a new mandate.
AB 2012 (Emmerson), Chapter 756 of the Statutes of 2006,
requires health plans and insurers to set benefit levels
for orthotic and prosthetic devices at no less than the
annual and lifetime benefit maximums applicable to basic
health care services, and limited out-of-pocket amounts for
those devices.
Arguments in support
The California Society of Plastic Surgeons (CSPS), sponsor
of SB 630, states that children born with cleft palate or
craniofacial anomalies have teeth that are missing,
malpositioned, or abnormally shaped; additionally, the jaw
may be in more than one piece because of bony clefts, and
the scars created to repair the cleft may impair the growth
of jawbone and teeth. Uncorrected, these dental
abnormalities can result in additional problems. CSPS
argues that dental care in such cases is obviously needed
for medical reasons, and that under current law some health
plans and insurers do not feel obligated to provide this
dental care.
The California Society of Pediatric Dentistry states that
the timing of dental and orthodontic services provided in
conjunction with surgical rehabilitation of congenial
craniofacial anomalies, trauma, or pathology is dictated by
the coordinated efforts of a team of medical and dental
specialists. An essential component of this care cannot be
removed without compromising the surgical result. The
California Society of Pediatric Dentistry argues, that for
instance, orthodontic services associated with craniofacial
anomalies are not separate or in addition to correction of
these defects, but an indispensable element of the
comprehensive medical treatment plan. The California
STAFF ANALYSIS OF SENATE BILL SB 630 (Steinberg)Page 6
Society of Pediatric Dentistry contends that, as such,
payment for these services should not be excluded from the
medical benefits designed to financially underwrite
reconstructive efforts.
Arguments in opposition
The National Federation of Independent Business (NFIB)
states that this bill would expand the existing
reconstructive surgery mandate to include dental and
orthodontic services. NFIB further states that the
cumulative impact of a number of mandated benefit bills in
the legislative process right now, in addition to the
benefit mandates already on the books, will significantly
increase premiums on employers and employees. NFIB
contends that, for small businesses, more than half of whom
cannot afford coverage for their employees, mandated bills
put coverage even further out of reach.
POSITIONS
Support: California Society of Plastic Surgeons (sponsor)
American Federation of State, County and
Municipal Employees (AFSCME)
California Dental Association
California Medical Association
California Society of Pediatric Dentistry
Oppose: National Federation of Independent Business
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