HBA-DMH C.S.S.B. 1411 77(R) BILL ANALYSIS Office of House Bill AnalysisC.S.S.B. 1411 By: Moncrief Public Health 5/5/2001 Committee Report (Substituted) BACKGROUND AND PURPOSE The House Committee on General Investigating conducted an interim investigation on the excessive use of stainless steel crowns and other aggressive dental procedures by certain providers in the Medicaid program. This investigation found some evidence of fraud in the Texas Health Steps Dental Services Program. Various procedures and certain billing codes offer providers the chance to defraud the dental program. The committee recommended various changes to help eliminate abuse of the system, and to improve the quality of services and care offered by the program. C.S.S.B. 1411 incorporates the recommendations of the House Committee on General Investigating to reduce fraud in the program. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority is expressly delegated to the Health and Human Services Commission in SECTION 1 (Section 32.053, Human Resources Code) of this bill. ANALYSIS C.S.S.B. 1411 amends the Human Resources Code to prohibit a dental service or product from being provided under Medicaid unless there is a dental necessity for the service or product. The bill requires the Health and Human Services Commission (HHSC), in providing dental services under the medical assistance program (Medicaid), to: _ensure that a stainless steel crown is not used as a preventive measure; _require a dentist participating in Medicaid to document, through x-rays or other methods established by HHSC rule, the dental necessity for a stainless steel crown before it is applied; _require a dentist participating in Medicaid to comply with a minimum standard of documentation and recordkeeping for each of the dentist's patients; _establish such a minimum standard in cooperation with the State Board of Dental Examiners; _replace the 15-point system used for determining the dental necessity for hospitalization and general anesthesia with a more objective and comprehensive system developed by HHSC; and _take all necessary action to eliminate unlawful acts in the provision of dental services under Medicaid. The bill requires HHSC, in setting reimbursement rates, to reduce the hospitalization fee and eliminate the nutritional consultation fee and redistribute amounts made available by such actions to other commonly billed dental services for which adequate accountability measures exist. The bill requires HHSC to set the reimbursement rate for a stainless steel crown at an amount equal to the reimbursement rate for an amalgam or resin filling. The bill requires HHSC to provide for reimbursement of a behavior management fee only under certain conditions and to redistribute amounts made available through the limitation of the behavior management fee to other commonly billed dental services for which adequate accountability measures exits. EFFECTIVE DATE On passage, or if the Act does not receive the necessary vote, the Act takes effect September 1, 2001. COMPARISON OF ORIGINAL TO SUBSTITUTE C.S.S.B. 1411 differs from the original by requiring the Health and Human Services Commission to set the reimbursement rate for a stainless steel crown at an amount equal to the reimbursement rate for an amalgam or resin filling.