GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1989

H	1 

HOUSE BILL 2326

Short Title:  Employee/Retiree Dental Benefits.	(Public)
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Sponsors: Representatives Hall; Warner and Bowman.
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Referred to:  Public Employees.
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June 6, 1990

A BILL TO BE ENTITLED
AN ACT TO PROVIDE DENTAL BENEFITS IN THE TEACHERS' AND STATE EMPLOYEES' COMPREHENSIVE MAJOR MEDICAL PLAN.
The General Assembly of North Carolina enacts:
Section 1.  Article 3 of Chapter 135 of the General Statutes is amended by adding a new section to read:
"§ 135-40.6B.  Dental Benefits.
Dental benefits are subject to deductibles and coinsurance provisions separate and apart from those provided for in G.S. 135-40.6.  No limits on out-of-pocket expenses are provided for dental benefits provided by this section.  Dental benefits are as follows:
(1)	The following dental benefits are provided with no deductible and are covered at ninety percent (90%) of charges allowed by the Plan:
a.	Diagnostic Services.
1.	Bitewing X rays:  once every 12 months.
2.	Full mouth X rays:  once every 36 months.
3.	Biopsies of oral tissue.
4.	Pulp vitality tests:  once every 12 months.
b.	Preventive Services.
1.	Oral examinations:  once every 12 months.
2.	Prophylaxis (scaling and polishing) and topical application of fluoride: once every 12 months.
    	3.	Sealants.
    	4.	Space maintainers: limited to covered individuals under age 19.
    	5.	Emergency treatment for the relief of pain and emergency oral examinations: coverage limited to permanent restorations or services provided under G.S. 135-40.6B(2)a. and G.S. 135-40.6B(3)a.
(2)	The following dental benefits are provided subject to a fifty dollar ($50.00) deductible per fiscal year for each covered individual and are covered on the basis of eighty percent (80%) by the Plan and twenty percent (20%) by the covered individual of charges allowed by the Plan:
	a.  Basic Services.
1.	Fillings.
2.	Periodontal treatments including gingivectomy, gingivoplasty, gingival flap curettage, periodontal prophylaxis and root planing and osseous surgery (flap entry and closure).
3.	Endodonics including root canal therapy.
4.	Oral surgery: limited to simple extractions, surgical removal of teeth and maxillary or mandibular cysts, and procedures performed for the preparation of the mouth for dentures.
5.	Apicoectomy.
6.	Hemisection.
7.	General anesthesia and injection of antibiotics:
	general anesthesia is covered only in connection with a covered dental service when administered by an individual licensed by the State to administer general anesthesia.
(3)	The following dental benefits are provided subject to the same fifty dollars ($50.00) deductible as contained in G.S. 135-40.6B(2) and are covered on the basis of fifty percent (50%) by the Plan and fifty percent (50%) by the covered individual of charges allowed by the Plan after application of the deductible:
a.	Major Services.
1.	Inlays, onlays and crowns.
2.	Installation of bridge work and dentures (complete or partial).
3.	Repair or replacement of crowns, inlays, onlays, bridgework or dentures, or rebasing/relining of dentures.
b.	Orthodontia. - Orthodontic treatments and appliances:
	limited to covered services rendered to qualified dependents under the age of 19.
(4)	Prior approvals. - Notwithstanding the provisions of G.S. 135-40.6A, prior approval of all dental treatment plans covered by this section and expected to cost more than two hundred dollars ($200.00) is required to be obtained from the Claims Processor.  The Plan will not cover any such treatment plans for which prior approval is not secured from the Claims Processor.
(5)	Alternate courses of treatment.- Payments for services covered by this section will be based on the procedure that is consistent with sound professional standards of dental practice for the dental condition treated and which carries the lesser charge.  The Executive Administrator and Board of Trustees may limit the Plan's reimbursement for the dental benefits provided by this section to amounts that would otherwise be allowed in accordance with G.S. 135-40.4.
(6)	Limitations and exclusions to dental benefits.- No benefits are allowed under this section for the following supplies, services, and charges:
a. 	Services rendered by other than licensed dentists (except for teeth cleaning and flouride applications performed by a licensed dental hygienist under the supervision and guidance of a dentist).
b.	Oral hygiene instructions, plaque control programs, and dietary instructions.
c.	Services which are experimental or investigative in nature.
d.	Gold foil fillings and restorations.
e.	Oral chemotherapy.
f.	Services covered by the Plan in sections of this Article other than in this section.
g.	Whole blood, blood components, and blood derivatives which are not classified as drugs in official formularies.
h.	Services to replace a lost or stolen prosthetic appliance.
i.	Services to replace a prosthetic appliance and cast restoration with a like appliance or cast restoration within five years of installation.  Such exclusion will not apply if replacement is needed due to accidental dental injury received while a covered individual, or if a replacement or addition is required to replace one or more teeth extracted after the existing denture or bridgework was installed while a covered individual.
j.	Services and supplies unnecessary to accepted dental practice.
k.	Services rendered by a provider who is a member of the covered individual's immediate family.
l.	Charges for telephone consultations, charges for failure to keep a scheduled visit, or charges for completion of a claim form.
m.	Implants.
(7)	Maximum benefits.
a.	The maximum annual benefit for each covered individual under this section is seven hundred fifty dollars ($750.00) per fiscal year.
b.	The maximum lifetime orthodontia benefit for each qualified dependent under the age of 19 covered under this section is seven hundred fifty dollars (750.00)."
Sec. 2.  G.S. 135-39.5B reads as rewritten:
"§ 135-39.5B. Prepaid plans.
The Executive Administrator and Board of Trustees may, after consultation with the Committee on Employee Hospital and Medical Benefits, provide for optional prepaid hospital and medical benefits plans and for optional prepaid dental plans. Benefits offered under such optional plans shall be comparable to those offered under the Plan. The amounts of State funds contributed for such optional plans shall not be more than the amounts contributed for each person eligible under G.S. 135-40.2 on a noncontributory Employee Only basis, with the person selecting an optional plan paying any excess, if necessary. The amount of State funds contributed to such optional plans shall also not exceed the amount of an optional plan's cost for Employee Only coverage. The Executive Administrator and Board of Trustees are authorized to assess and collect fees from participating optional plans provided by this section for administrative purposes and for risk management purposes. Such fees may be based upon the enrollees' risk factors and the number and types of contracts enrolled by each participating optional plan, and may be collected by the Plan in a manner prescribed by the Executive Administrator and Board of Trustees."
Sec. 3.  G.S. 135-40.6(9)b. reads as rewritten:
"b.	Dental care except as covered under subsection (8)f and other dental services covered by the surgical benefits section of this Plan, subsection (5)c of this section, and G.S. 135-40.6B;".
Sec. 4.  This act shall become effective October 1, 1991.