23-86-121. Coverage for anesthesia and hospitalization for dental procedures.

23-86-121. Coverage for anesthesia and hospitalization for dental procedures. (a) As used in this section, “health benefit plan” means any policy, contract, or agreement offered by an insurance company, health maintenance organization, or hospital and medical service corporation to provide, reimburse, or pay for healthcare services, but does not include the following: (1) Workers' compensation coverage; (2) Self-funded or self-insured health plans, unless the plan is established or maintained for employees of a governmental or church entity; (3) Health plans covering specific diseases other than dental plans; (4) Hospital indemnity insurance; (5) Long-term care insurance; (6) Short-term limited duration insurance; (7) Accident only insurance; (8) Medicare supplement insurance; or (9) Other supplemental insurance. (b) Health benefit plans shall provide coverage for payment of anesthesia and hospital or ambulatory surgical facility charges for services performed in connection with dental procedures in a hospital or ambulatory surgical facility, if: (1) The provider treating the patient certifies that because of the patient's age or condition or problem, hospitalization or general anesthesia is required in order to safely and effectively perform the procedures; and (2) The patient is: (A) A child under seven (7) years of age who is determined by two (2) dentists licensed under the Arkansas Dental Practice Act, § 17-82-101 et seq., to require without delay necessary dental treatment in a hospital or ambulatory surgical center for a significantly complex dental condition; (B) A person with a diagnosed serious mental or physical condition; or (C) A person with a significant behavioral problem as determined by the covered person's physician as licensed under the Arkansas Medical Practices Act, § 17-95-201 et seq., § 17-95-301 et seq., and § 17-95-401 et seq. (c) The health benefit plan may apply deductibles, coinsurance, network requirements, medical necessity determinations, and other limitations as are applied to other covered services. (d) The health benefit plan may require prior authorization for hospitalization for dental care procedures in the same manner that prior authorization is required for hospitalization for other covered medical conditions. (e) If a person is covered under both a health benefit plan that provides dental benefits and a health benefit plan that provides medical benefits, the health benefit plan that includes dental benefits is the primary payer and the health benefit plan that provides medical benefits is the secondary payer, subject to subsections (h) and (i) of this section. (f) This section does not apply to treatment rendered for temporomandibular joint disorders. (g)(1) This section applies to health benefit plans that are issued, renewed, extended, or modified on and after January 1, 2006. (2) “Renewed, extended, or modified” includes a change in premium or other financial term. (h) This section does not require a health benefit plan that does not cover dental benefits to cover dental care for which general anesthesia or hospital or ambulatory surgical facility services, or both, are performed in connection with dental procedures. (i) This section does not require a health benefit plan that does not cover charges for hospital or ambulatory surgical facilities generally to cover charges for hospital or ambulatory surgical facilities in connection with dental procedures described in subsection (b) of this section.