BILL ANALYSIS
SB 630
Page 1
Date of Hearing: June 30, 2009
ASSEMBLY COMMITTEE ON HEALTH
Dave Jones, Chair
SB 630 (Steinberg) - As Amended: June 22, 2009
SENATE VOTE : 34-0
SUBJECT : Health care coverage: cleft palate reconstructive
surgery: dental and orthodontic services.
SUMMARY : Clarifies that the existing requirement for health
plans and health insurers to cover reconstructive surgery
includes, but is not limited to, medically necessary dental or
orthodontic services that are an integral part of reconstructive
surgery for cleft palates. Specifically, this bill :
1)Clarifies that the requirement in existing law for health
plans and health insurers to provide coverage for
reconstructive surgery applies to medically necessary dental
or orthodontic services that are an integral part of
reconstructive surgery for cleft palates performed to improve
function or to create a normal appearance, to the extent
possible.
2)Defines "cleft palate" for purposes of this bill as a
condition that may include cleft palate, cleft lip, or related
craniofacial anomalies.
3)Exempts from the provisions of this bill certain contracts
entered into between the Department of Health Care Services
and a health plan for enrolled Medi-Cal beneficiaries that do
not cover services provided by the California Children's
Services program, as specified.
4)Expresses legislative intent to reaffirm that existing law
governing reconstructive surgery applies to coverage for
dental and orthodontic services that are a necessary and
essential part of reconstructive surgery to address cleft
palate cases and other medical conditions.
EXISTING LAW :
1)Provides for the regulation of health plans by the Department
of Managed Health Care (DMHC) and health insurers by the
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California Department of Insurance (CDI).
2)Requires health plans licensed under the Knox-Keene Health
Care Service Plan Act of 1975 (Knox-Keene) to cover all
medically necessary basic health care services, as defined.
Defines basic health care services to include: physician
services; hospital inpatient and outpatient services,
including outpatient physical, occupational, and speech
therapy; diagnostic laboratory and x-ray services; preventive
and routine care, such as vaccinations and routine checkups;
emergency and urgent care services, including ambulance and
out-of-area emergency services; and, medically appropriate
home health services. There is no requirement for health
insurers subject to regulation by CDI to cover medically
necessary basic services or any specific minimum basic
benefits.
3)Requires every health plan and every health insurer, to cover
or offer coverage for specified mandated benefits or types of
coverage. Mandated benefits and mandated offerings may apply
to individual coverage, group coverage, or both, depending on
the statutory requirements related to that benefit, and in
most instances, apply equally to health plans and health
insurers. There are some specific mandates or mandated
offerings that apply only to health plans or only to health
insurers.
4)Requires health plans and health insurers to provide coverage
for reconstructive surgery that is necessary to improve
function or create a normal appearance to the extent possible.
5)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.
6)Permits health plans and insurers to apply prior authorization
and utilization review procedures to requests for
reconstructive surgeries, as specified.
FISCAL EFFECT : The current provisions of this bill have not
yet been analyzed by a fiscal committee.
COMMENTS :
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1)PURPOSE OF THIS BILL . According to the author, children with
cleft palates often undergo reconstructive surgery performed
by a team of medical specialists, not for cosmetic reasons,
but to correct extra or missing teeth or extremely misplaced
and misshapen teeth and jaws. The author argues that these
children need orthodontic services for medical reasons but
cannot obtain coverage unless they have separate dental
insurance, which may not entirely cover the substantial
expenses associated with cleft palate repair. The author
points out that existing law requiring health plans and health
insurers to provide coverage for reconstructive surgery,
including surgeries to correct or repair congenital defects
and developmental abnormalities, such as oral clefts, does not
explicitly include orthodontic procedures for oral cleft
repair as covered services. This bill is intended to clarify
that medically necessary dental and orthodontic services must
be covered for the purpose of reconstructive surgery that is
performed for cleft palate procedures.
2)BACKGROUND . According to the California Birth Defects
Monitoring Program (CBDMP), 1 in 790 babies in California is
born with an oral cleft. Oral clefts occur when the tissues
of the infant's developing mouth fail to meet and fuse between
five and nine weeks gestation. The cause of oral clefts is
unknown but evidence points to interactions between genetics
and environmental factors, such as linkages between smoking
during pregnancy and the presence of the cleft-susceptibility
gene. Surgery to close clefts is done in infancy, but most
individuals require additional operations during childhood and
adolescence; often four surgeries before the age of two.
Babies with oral clefts may have feeding problems and often
have ear infections, experience speech difficulties, and
require orthodontic treatment as they grow older. The CBDMP
estimates that about 15% of all babies with oral clefts die
before the first year of age, usually due to associated birth
defects, and the average lifetime cost for medical treatment,
educational services, and lost productivity for individuals
with these conditions exceeds $100,000.
3)CURRENT COVERAGE REQUIREMENT . Existing law requires health
plans and health insurers to cover reconstructive surgery,
including surgeries to correct or repair congenital defects
and developmental abnormalities, such as oral clefts. DMHC
reports that, as is the case with other reconstructive
surgeries that affect the mouth, dental and orthodontic
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procedures may be considered part of oral cleft reconstructive
surgery if deemed medically necessary. DMHC has a neutral
position on a prior version of this bill, stating that this
bill helps to clarify and confirm services that are required
under Knox-Keene when medically necessary to provide or
complete the reconstructive surgery. Additionally, DMHC notes
that the intent language in this bill is important in ensuring
that the provisions of the bill are not construed to limit or
prevent coverage for dental or orthodontic services in other
situations where they are medically necessary and an essential
part of reconstructive surgery to address other medical
conditions caused from trauma or cancer, for example.
4)INDEPENDENT MEDICAL REVIEW . Individuals covered by health
plans or health insurers in California are entitled to an
independent medical review (IMR) if a health plan or insurer
denies health care services or payment for health care
services based on medical necessity. An IMR is a process
where expert independent medical professionals are selected to
review specific medical decisions made by the plans or
insurers. DMHC and CDI administer the IMR program to enable
consumers to request an impartial appraisal of medical
decisions within certain guidelines specified in law. An IMR
can only be requested if the plan or insurer's decision
involves the medical necessity of a treatment, an experimental
or investigational therapy for certain medical conditions, or
a claims denial for emergency or urgent medical services.
DMHC maintains an online searchable database that allows
consumers to review IMR decisions. According to information
from the database, there has been one case in which a
24-year-old male was denied dental and orthodontic treatment
related to his cleft lip and palate. Specifically, the
enrollee's parent requested dental implants for the treatment
of the enrollee's cleft lip/palate and congenital
malformation. The physician reviewer noted that patients with
facial clefting present many challenges and the goal of
treatment is to provide normal function and esthetic
appearance. According to the reviewer, optimal management of
patients with cleft lip and palate, which can often last into
the patient's late teenage years to early twenties, is usually
done under the direction of a multidisciplinary team in order
to achieve satisfactory results. The reviewer indicated that
specific therapeutic goals for maxillofacial deformities
include improving chewing and swallowing, contact between the
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teeth, and dental and periodontal health. In this particular
case, the reviewer found that, because the enrollee had
missing and malformed teeth associated with his cleft lip and
palate, dental implant placement to reconstruct his jaw was
necessary in order to achieve the therapeutic goals for a
patient with these deformities. Lastly, the physician
reviewer noted that reconstructive surgeries performed to
correct deformities caused by congenital or developmental
abnormalities for the purpose of improving bodily function or
creating a normal appearance was a covered benefit in the
enrollee's plan. The health plan's denial of coverage based
on medical necessity was subsequently overturned and the plan
covered the disputed treatment.
5)SUPPORT . The California Society of Plastic Surgeons (CSPS),
the sponsor of this bill, states that children born with cleft
palate or craniofacial anomalies have teeth that are missing,
malpositioned, or abnormally shaped or jaws that may be in
more than one piece because of bony clefts. CSPS notes that
the scars created to repair the cleft may impair the growth of
jawbone and teeth and, if left uncorrected, these dental
abnormalities can result in additional problems. CSPS argues
that dental care for children in these cases is obviously
needed for medical reasons but, under current law, some health
plans and insurers do not feel obligated to provide this care.
The California Dental Association (CDA) writes in support
that the clarification in this bill is needed to ensure that
dental or orthodontic services that are medically necessary
and related to reconstructive surgery for cleft palate
procedures are appropriately covered. CDA believes this bill
would benefit children born with cleft palate who often need
multi-disciplinary treatment from specialists, such as oral
and maxillofacial surgeons and periodontists, to complete the
comprehensive care required to restore them to full health and
function. The California Medical Association adds that
medically necessary reconstructive work should be covered by
health plans and insurers because it has a severe impact on a
patient's overall well-being as the myriad of abnormalities
associated with cleft palate can result in additional health,
dental, and social problems unless corrected.
6)OPPOSITION . Health plans, health insurers, and business
groups object to this bill, contending that it constitutes an
expansion of the existing reconstructive surgery mandate.
The California Association of Health Plans (CAHP) states that,
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under current law, health plans and insurers are responsible
for making a child with a cleft palate able to subsequently
have braces, like any other child, but nothing in existing law
requires plans or insurers to be responsible for covering the
orthodontia; therefore, according to CAHP, this bill is more
than a clarification of existing law. The Association of
California Life and Health Insurance Companies and the
California Chamber of Commerce agree with CAHP that this bill
is an expansion of coverage and they argue that it warrants a
review by the California Health Benefits Review Program for
its impact on premiums. Blue Shield of California writes in
opposition that it has adopted a policy of resisting most new
mandates, including this bill, because of the additional costs
imposed on its members, even if the motivation for the mandate
is legitimate and understandable. Lastly, opponents assert
that they remain very concerned about the cumulative effect of
benefit mandates on premiums and coverage levels, particularly
at a time when individuals and employers are trying to afford
coverage.
REGISTERED SUPPORT / OPPOSITION :
Support
California Society of Plastic Surgeons (sponsor)
California Dental Association
California Medical Association
Opposition
Association of California Life & Health Insurance Companies
Blue Shield of California
California Association of Health Plans
California Chamber of Commerce
National Federation of Independent Business
Analysis Prepared by : Cassie Rafanan / HEALTH / (916)
319-2097