GENERAL ASSEMBLY OF NORTH CAROLINA

SESSION 1997

S	1 

SENATE BILL 1557

Short Title:  Dental, Vision, Hearing Benefits.	(Public)

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Sponsors: Senators Rand; Ballance, Cochrane, Cooper, Hoyle, Lee, Odom, Perdue, Plyler, Soles, and Winner.

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Referred to:  State Government, Local Government, and Personnel.

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June 1, 1998

A BILL TO BE ENTITLED
AN ACT TO PROVIDE DENTAL, VISION, AND HEARING BENEFITS FOR DEPENDENT CHILDREN UNDER THE AGE OF NINETEEN YEARS IN THE TEACHERS' AND STATE EMPLOYEES' COMPREHENSIVE MAJOR MEDICAL PLAN.
The General Assembly of North Carolina enacts:
Section 1.  G.S. 135-40.5(e) reads as rewritten:
"(e)	Routine Diagnostic Examinations. – The Plan will pay one hundred percent (100%) of allowable charges for routine diagnostic examinations and tests, including Pap smears, breast, colon, rectal, and prostate exams, X rays, mammograms, blood and blood pressure checks, urine tests, tuberculosis tests, and general health checkups that are medically necessary for the maintenance and improvement of individual health but no more often than once every three years for covered individuals age 7 years to age 40 years, once every two years for covered individuals  to age 50 years, and once a year for covered individuals age 6 years and younger and age 50 years and older, unless a more frequent occurrence is warranted by a medical condition when such charges are incurred in a medically supervised facility.  The following additional services are covered by the provisions of this section when provided to dependent children under 19 years of age: (i) dental oral examinations, teeth cleaning, and scaling twice during a 12-month period, full mouth X rays once every 60 months, supplemental bitewing X rays showing the back of the teeth once during a 12-month period, and fluoride applications once during a 12-month period; (ii) scheduled routine eye examinations once every 12 months; and (iii) auditory diagnostic testing services.  Provided, however, that charges for such examinations and tests are not covered by the Plan when they are incurred to obtain or continue employment, to secure insurance coverage, to comply with legal proceedings, to attend schools or camps, to meet travel requirements, to participate in athletic and related activities, or to comply with governmental licensing requirements. The maximum amount payable under this subsection for a covered individual is one hundred fifty dollars ($150.00) per fiscal year."
Section 2.  G.S. 135-40.6(8) is amended by adding a new sub-subdivision to read:
"u.	Additional Services and Supplies for Dependent Children Under 19 Years of Age:  The following services and supplies not otherwise covered by this Part are covered by the Plan only for dependent children under 19 years of age:
1.	Dental:  Oral examinations, teeth cleaning, and scaling twice during a 12-month period, full mouth X rays once every 60 months, supplemental bitewing X rays showing the back of the teeth once during a 12-month period, fluoride applications once during a 12-month period, and routine fillings of amalgam or other tooth-colored filling material to restore diseased teeth.  No benefits are to be provided for services under this sub-subdivision that are not performed by or upon the direction of a dentist, doctor, or other professional provider approved by the Plan nor for services and materials that do not meet the standards accepted by the American Dental Association.
2.	Vision:  Scheduled routine eye examinations once every 12 months, eyeglass lenses or contact lenses once every 12 months, routine replacement of eyeglass frames once every 24 months, and optical supplies and solutions when needed.  Optical services, supplies, and solutions must be obtained from licensed or certified opthamologists, optometrists, or optical dispensing laboratories.  Eyeglass lenses are limited to single vision, bifocal, trifocal, or other complex lenses necessary for a Plan enrollee's visual welfare.  Coverage for oversized lenses and frames, designer frames, photosensitive lenses, tinted contact lenses, blended lenses, progressive multifocal lenses, coated lenses, and laminated lenses is limited to the coverage for single vision, bifocal, trifocal, or other complex lenses provided by this sub-subdivision.  Eyeglass frames are limited to those made of zylonite, metal, or a combination of zylonite and metal.  All visual aids covered by this sub-subdivision require prior approval of the Plan.  Upon prior approval by the Plan, refractions may be covered more often than once every 12 months.
3.	Hearing:  Auditory diagnostic testing services and hearing aids and accessories when provided by a licensed or certified audiologist, otolaryngologist, or other hearing aid specialist approved by the Plan.  Prior approval of the Plan is required for hearing aids, accessories, earmolds, repairs, loaners, and rental aids."
Section 3.  (a)	G.S. 135-40.6(8)f. reads as rewritten:
"f.	Dental Services: Oral surgery, including extraction of teeth, necessitated because of medical treatment. Dental surgery and appliances for mouth, jaw, and tooth restoration necessitated because of external violent and accidental means, such as the impact of moving body, vehicle collision, or fall occurring while an individual is covered under G.S. 135-40.3. No benefits are provided in connection with injury incurred in the act of chewing, nor for damage or breakage of an appliance such as bridge or denture being cleaned or otherwise not in normal mouth usage at the time of accident, nor for appliances for orthodontic treatment when a class of malocclusion, other than orthognathic, or cross bite has been diagnosed. Benefits for temporomandibular joint (TMJ) disfunction appliance therapy are limited to cases where the TMJ disfunction has been diagnosed as solely resulting from accidental means as certified by the attending practitioner and approved by the Claims Processor.
		Benefits shall include extractions, fillings, crowns, bridges, or other necessary therapeutic and restorative techniques and appliances to reasonably restore condition and function to that existing immediately prior to the accident. Injury or breakage of existing appliances such as bridges and dentures is limited to repair of such appliances unless certified as damaged beyond repair.
		The provisions of this sub-subdivision shall not apply to the benefits provided in G.S. 135-40.6(8)u."
(b)	G.S. 135-40.6(9)b. reads as rewritten:
"b.	Dental care except as covered under sub-subdivisions (8)f. and (8)u. and other dental services covered by the surgical benefits section of this Plan, subsection (5)c of this section;".
(c)	G.S. 135-40.6(9)f. reads as rewritten:
"f.	Eyeglasses or other corrective lenses (except for cataract lenses certified as medically necessary for aphakia persons), hearing aids, braces for teeth, dental plates or bridges or other dental prostheses, air-conditioners, vaporizers, humidifiers, mattresses (other than as supplied with a hospital bed) and specially built shoes (other than attached to artificial limbs or orthopedic braces) not covered by the provisions of G.S. 135-40.6(8)u.;".
(d)	G.S. 135-40.7(11) reads as rewritten:
"(11)	Charges for or in connection with any dental work or dental treatment except to the extent that such work or treatment is specifically provided for under the Plan. Excluded is payment for surgical benefits for tooth replacement, such as crowns, bridges or dentures; orthodontic care; filling of teeth; extraction of teeth (whether or not impacted); root canal therapy; removal of root tips from teeth; treatment for tooth decay, inflammation of gingiva, or surgical procedures on diseased gingiva or other periodontal surgery; repositioning soft tissue, reshaping bone, and removal of bony projections from the ridges preparatory to fitting of dentures; removal of cysts incidental to removal of root tips from teeth and extraction of teeth; or other dental procedures involving teeth and their bones or tissue supporting structure except as provided by the provisions of G.S. 135-40.6(8)u."
(e)  G.S. 135-40.7(13) reads as rewritten:
"(13)	Charges for eyeglasses or other corrective lenses (except for cataract lenses certified as medically necessary for aphakia persons) and hearing aids or examinations for the prescription or fitting thereof except as provided by the provisions of G.S. 135-40.6(8)u."
(f)  G.S. 135-40.6(6)a. reads as rewritten:
"a.	No benefits are provided for dental prostheses such as crowns, or dentures; orthodontic care; operative restoration of teeth (fillings); dental extractions (whether impacted or not impacted); apicoectomies; treatment of dental caries, gingivitis, or periodontal diseases by gingivectomies or other periodontal surgery; vestibuloplasties, alveoplasties, removal of exostosis and tori preparatory to fitting of dentures; correction of malocclusion by orthognathic surgery or other procedures by repositioning of bone tissue except as permitted pursuant to G.S. 135-40.6(5)c; removal of cysts incidental to apicoectomies or extraction of teeth.  Nothing in this sub-subdivision shall limit the benefits provided by the provisions of G.S. 135-40.6(8)u."
Section 4.  This act becomes effective January 1, 1999.