RD108 - Evaluation of Senate Bill 81: Mandated Coverage for General Anesthesia and Hospitalization for Pediatric Dental Procedures


Executive Summary:
Senate Bill 81 (SB 81) of the 2012 General Assembly Session would amend Section 38.2-3418.12 of the Code of Virginia, which mandates health insurance coverage for medically necessary general anesthesia and hospitalization charges in pediatric dental procedures. Specifically, SB 81 increases the age under which coverage must be provided for medically necessary general anesthesia and hospitalization charges from five to 13. As is the case with the existing mandate, insurance providers would not be required to cover the costs of the dental procedure for which general anesthesia is being used. SB 81 would only require insurers to cover the costs of the general anesthesia and its administration in a hospital or outpatient surgical facility, and would not require insurers to cover these costs in a dentist’s office.

MEDICAL EFFICACY AND EFFECTIVENESS

General anesthesia’s three goals are rendering the patient unconscious, free of pain, and immobilized. While other behavior management techniques and/or medications can achieve one or two of these goals, only general anesthesia can meet all three in a safe, effective, and humane fashion. The medical efficacy of general anesthesia for dental treatments has not been thoroughly reviewed, in part due to ethical issues that arise when denying it to patients who need it. However, medical experts indicate that general anesthesia is very effective, and that no sedation alternatives can achieve all three goals as safely and effectively.

SOCIAL IMPACT

Utilization of general anesthesia for dental procedures appears to be very low (less than 0.15 percent), and most children between the ages of five and 12 who require hospital-based general anesthesia appear to be covered by the existing mandate’s “medical condition” or “severe disability” provisions. Most insurers report already providing the coverage in SB 81, and the State employee health plan reports no denials of claims for general anesthesia in dental patients between the ages of five and 12. However, based on interviews with medical experts, some patients between the ages of five and 12 may not be covered because they cannot meet the insurers’ interpretations of the existing mandate’s “severely disabled” or “medical condition” provisions. The out-of-pocket cost for general anesthesia and hospitalization for these children is significant, ranging from approximately $9,000 to $23,300.

FINANCIAL IMPACT

SB 81 is not expected to result in significant changes to the utilization of general anesthesia in a hospital setting or the cost of providing such services, nor is it expected to substantially increase premium and administrative costs. Similarly, little to no change is expected over the next five years in the number or types of providers who administer general anesthesia in a hospital setting. The financial impact of the proposed mandate is expected to be low, primarily because the bill is not expected to significantly increase the utilization, as most children who require such services are likely already covered under the existing mandate. This is consistent with the experience insurers report for the existing mandate. Importantly, provisions of federal health care reform legislation would require the State to cover all costs associated with SB 81.

BALANCING MEDICAL, SOCIAL, AND FINANCIAL CONSIDERATIONS

The proposed mandate is consistent with the role of health insurance and may provide access to medically necessary general anesthesia in a hospital setting for some patients. However, it appears that the mandate is attempting to address concerns regarding the safety of office-based general anesthesia for dental procedures and to ensure that patients who should qualify under the existing mandate receive coverage. If these are the primary goals, then it appears that assuring an adequate regulatory environment for the use of general anesthesia for dental procedures and clarifying language in the existing mandate about when coverage is required would more directly address these goals than the amendments in SB 81.