Bulletin LH 2010-01: Medically Necessary Dental Procedure for Minors

Five Corporate Plaza • 3625 NW 56TH • Suite 100 • OKLAHOMA CITY, OK 73112 • (405) 521-3681 • IN STATE 1-800-522-0071 • FAX (405) 522-3761 Oklahoma INSURANCE Department State of Oklahoma TO: ALL LIFE & HEALTH INSURERS ALL LIFE & HEALTH PRODUCERS ALL THIRD PARTY ADMINISTRATORS FROM: OKLAHOMA INSURANCE DEPARTMENT RE: MEDICALLY NECESSARY DENTAL PROCEDURE FOR DISABLED OR MINORS – SECTION 6060.6 OF TITLE 36 DATE: JANUARY 12, 2010 PURPOSE OF THIS BULLETIN Section 6060.6 of Title 36 requires certain health benefit plans to provide coverage for anesthesia and hospital and ambulatory surgical center expenses in connection with medically necessary dental procedures when a covered person meets specific criteria. This bulletin clarifies the position of the Insurance Department when coverage is medically necessary for dental procedures for children eight years old or younger. Subsection A of Section 6060.6 of Title 36 of the Oklahoma Statutes requires health benefit plans providing hospitalization benefits to also provide coverage for anesthesia expenses and hospital and ambulatory surgical center expenses associated with any medically necessary dental procedure when a covered person is either: 1. Severely disabled, or 2. A minor who is eight years of age or under, and who has a medical or emotional condition which requires hospitalization or general anesthesia for dental care. As written, the statute does not refer to a behavioral condition of a child eight or younger, nor does the statute require a diagnosis of a medical, behavioral or emotional condition of the child in order to receive covered benefits for anesthesia or expenses associated with medically necessary dental procedures. The statute refers to a child eight years or younger who has an emotional condition requiring hospitalization or anesthesia. What constitutes an “emotional condition” is a broad term which can encompass a variety of meanings. Bulletin No. Page 2 of 2 While the emotional development of child can change rapidly as the child matures, the intent of the law appears to be to ensure that a young child is not unnecessarily traumatized or physically harmed by a major dental procedure. The physical and emotional safety of the child is of the utmost importance. Reason dictates that a young child is not of sufficient emotional development to undergo medically necessary dental procedures involving time and restraint. Therefore, it is the position of the Insurance Department that the intent of the statute is that health benefit plans falling under the purview of Section 6060.6 of Title 36 provide coverage for anesthesia expenses and hospital and ambulatory surgical center expenses associated with any medically necessary dental procedure for minors under the age of eight, taking into consideration the professional judgment of the practitioner treating the child concerning the use of anesthesia in conjunction with the performance of the procedure. Section 6060.6 can be read in its entirety by clicking on the following link: http://www.oscn.net/applications/oscn/DeliverDocument.asp?CiteID=103738. Questions regarding this bulletin should be directed to Lydia Shirley, Lydia.Shirley@oid.ok.gov, of the Consumer Assistance Division, or Susan Dobbins, Susan.Dobbins@oid.ok.gov, of the Legal Division at P.O. Box 53408, Oklahoma City, Oklahoma 73152-3408. The Oklahoma Insurance Department Encourages readers of this notice to periodically check the Department’s website at: http://www.ok.gov/oid/ for news and updates to Bulletins and other relevant material.