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The Vermont Statutes Online



Title

08

:
Banking and Insurance






Chapter

107

:
HEALTH INSURANCE






Subchapter

012
:
COVERAGE FOR DENTAL PROCEDURES










 

§

4100i. Anesthesia coverage for certain dental procedures

(a) A health

insurance plan shall provide coverage for the hospital or ambulatory surgical

center charges and administration of general anesthesia administered by a

licensed anesthesiologist or certified registered nurse anesthetist for dental

procedures performed on a covered person who is:

(1) a child

seven years of age or younger who is determined by a dentist licensed pursuant

to 26 V.S.A. chapter 13 to be unable to receive needed dental treatment in an

outpatient setting, where the provider treating the patient certifies that due

to the patient's age and the patient's condition or problem, hospitalization or

general anesthesia in a hospital or ambulatory surgical center is required in

order to perform significantly complex dental procedures safely and

effectively;

(2) a child 12

years of age or younger with documented phobias or a documented mental

condition or psychiatric disability, as determined by a physician licensed

pursuant to 26 V.S.A. chapter 23 or by a licensed mental health professional,

whose dental needs are sufficiently complex and urgent that delaying or

deferring treatment can be expected to result in infection, loss of teeth, or

other increased oral or dental morbidity; for whom a successful result cannot

be expected from dental care provided under local anesthesia; and for whom a

superior result can be expected from dental care provided under general

anesthesia; or

(3) a person who

has exceptional medical circumstances or a developmental disability, as

determined by a physician licensed pursuant to 26 V.S.A. chapter 23, which

place the person at serious risk.

(b) A health

insurance plan may require prior authorization for general anesthesia and

associated hospital or ambulatory surgical center charges for dental care in

the same manner that prior authorization is required for these benefits in

connection with other covered medical care.

(c) A health

insurance plan may restrict coverage for general anesthesia and associated

hospital or ambulatory surgical center charges to dental care that is provided

by:

(1) a fully

accredited specialist in pediatric dentistry;

(2) a fully

accredited specialist in oral and maxillofacial surgery; and

(3) a dentist to

whom hospital privileges have been granted.

(d) The

provisions of this section shall not be construed to require a health insurance

plan to provide coverage for the dental procedure or other dental care for

which general anesthesia is provided.

(e) The

provisions of this section shall not be construed to prevent or require

reimbursement by a health insurance plan for the provision of general

anesthesia and associated facility charges to a dentist holding a general

anesthesia endorsement issued by the Vermont Board of Dental Examiners if the

dentist has provided services pursuant to this section on an outpatient basis

in his or her own office and the dentist is in compliance with the

endorsement's terms and conditions.

(f) As used in

this section:

(1)

"Ambulatory surgical center" shall have the same meaning as in 18

V.S.A. § 9432.

(2)

"Anesthesiologist" means a person who is licensed to practice

medicine or osteopathy under 26 V.S.A. chapter 23 or 33 and who either:

(A) has

completed a residency in anesthesiology approved by the American Board of

Anesthesiology or the American Osteopathic Board of Anesthesiology or their

predecessors or successors; or

(B) is

credentialed by a hospital to practice anesthesiology and engages in the

practice of anesthesiology at that hospital full-time.

(3) "Certified

registered nurse anesthetist" means an advanced practice registered nurse

licensed by the Vermont Board of Nursing to practice as a certified registered

nurse anesthetist.

(4) "Health

insurance plan" means any health insurance policy or health benefit plan

offered by a health insurer, as defined in 18 V.S.A. § 9402, but does not

include policies or plans providing coverage for a specified disease or other

limited benefit coverage.

(5)

"Licensed mental health professional" means a licensed physician,

psychologist, social worker, mental health counselor, or nurse with

professional training, experience, and demonstrated competence in the treatment

of a mental condition or psychiatric disability. (Added 2009, No. 128 (Adj.

Sess.), § 34, eff. Oct. 1, 2010; amended 2013, No. 96 (Adj. Sess.), § 20.)