§ 15-828
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/md/insurance/15-828A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
§15–828.
(a)This section applies to:
(1)insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense-incurred basis under health insurance policies that are issued or delivered in the State; and
(2)health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.
(b)An entity subject to this section shall provide coverage for general anesthesia and associated hospital or ambulatory facility charges in conjunction with dental care provided to an enrollee or insured if the enrollee or insured:
(i)is 7 years of age or younger or is developmentally disabled;
(ii)is an individual for whom a successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual, or other medically compromising condition of the enrollee or insured; and
(iii)is an individual for whom a superior result can be expected from dental care provided under general anesthesia; or
(i)is an extremely uncooperative, fearful, or uncommunicative child who is 17 years of age or younger with dental needs of such magnitude that treatment should not be delayed or deferred; and
(ii)is an individual for whom lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity.
(c)An entity subject to this section may require prior authorization for general anesthesia and associated hospital or ambulatory facility charges for dental care in the same manner that prior authorization is required for these benefits in connection with other covered medical care.
(d)An entity subject to this section may restrict coverage for general anesthesia and associated hospital or ambulatory facility 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.
(e)The provisions of this section may not be construed to require coverage for the dental care for which the general anesthesia is provided.
(f)The provisions of this section do not apply to dental care rendered for temporal mandibular joint disorders.