Meeting Dial-in #: 1-669-900-6833 Meeting ID: 98232307536
General Business: 9.3
The City of Sparks Group Health Care Committee (GHCC) was established through contract negotiations for the purpose of recommending to the City Council cost containment and benefit changes to the City’s self-insured group health plan (the Plan). Modifications may include changes to medical, dental, pharmacy, and life insurance benefits as outlined in the City of Sparks Group Health Summary Plan Document (Plan Document).
The Plan Document is the foundation and governing record for the City’s contracted third-party administrators, such as Hometown Health and MaxorRx, to determine benefits coverage and to pay claims.
The GHCC meets six (6) times per year to discuss the benefits affecting members. Discussions may include but are not limited to the financial status of the Plan, cost containment measures, state- and federally mandated benefit changes, interpretation of the Plan Document, language changes to the Plan Document, and reviews of services provided by the City’s contracted third-party administrators. The GHCC meetings comply with Nevada Open Meeting Law.
Composition of the GHCC
Two (2) groups comprise the GHCC. Operating Engineers Local 3, the Sparks Police Protective Association, and International Association of Firefighters Local 1265 are the voting groups on the GHCC. Each voting group has one voting member and one alternate who are appointed to their positions by the membership of their respective recognized bargaining units.
In addition, Operating Engineers Local 3 Supervisory Unit; Classified Chief Officers; Confidential Employees; Management, Professional, Technical and Appointed Employees; and Retirees are the five non-voting represented groups on the GHCC. One primary member and one alternate represent each non-voting represented group. Operating Engineers Local 3 Supervisory Unit and Classified Chief Officers select and appoint their own representatives. The City Manager selects and appoints the representatives for Confidential Employees; Management, Professional, Technical and Appointed Employees; and Retirees. The application process for Retirees follows the application process for other City boards and commissions.
A Chair, Vice-Chair and Secretary of the GHCC are selected and appointed by the City Manager and need not otherwise be members or alternates on the GHCC. Other City staff and representatives from the City's contracted third-party administrators and other contractors also attend GHCC meetings.
Request to Change Plan Document
In the event a member of the GHCC proposes a change to the plan document, the Chair may place the item on a future agenda. The GHCC member requesting the change and Human Resources staff work together to research the proposed change and gather pertinent information from partners such as Hometown Health to allow the GHCC to make an informed decision on the proposed change.
When the item is scheduled for the GHCC's review, discussion, and possible action, the GHCC may make a motion and vote on the proposed plan change. If GHCC approves the change, the proposed change will appear before City Council at a future meeting for consideration.
At its November 19, 2020 meeting, the GHCC approved changing the Plan Document to cover basic/conscious sedation for dental procedures when deemed medically necessary. The details of the proposed changes to the Plan Document are discussed in the Analysis section below.
City Council is being asked to approve a change in dental benefits in the Plan Document to reflect coverage for basic/conscious sedation (Nitrous Oxide), which will allow covered members to receive Nitrous Oxide during dental procedures when deemed medically necessary. At the regularly scheduled September 17, 2020 GHCC meeting, a member of the GHCC asked that an agenda item be added at the next regularly scheduled meeting to discuss the Plan Document language for dental anesthesia. It was requested that Nitrous Oxide, commonly known as “laughing gas” and defined as basic/conscious sedation, be added as a covered benefit under the Plan Document.
Research was compiled by Human Resources to determine:
- The current definition in the Plan Document for dental anesthesia.
- How the benefit was being interpreted and paid by Hometown Health, the City’s third-party medical and dental benefit administrator.
- Whether or not basic/conscious sedation is recommended by the American Dental Association and is deemed medically necessary.
- If basic/conscious sedation is widely used in dental practices today and covered by other agencies.
At the November 19, 2020 GHCC meeting, members were presented with the requested information and research, which is also discussed below.
The Plan Document currently defines dental anesthesia as follows:
Anesthesia - General anesthesia when administered for oral surgery. Hypnosis and relative analgesia are covered only if the patient is completely anesthetized to a state of unconsciousness as with a general anesthetic. Separate charges for pre-medication, local anesthesia, analgesia or conscious sedation are not covered. Such services should be included in the cost of the procedure itself.
Interpretation of Plan Document and Payment of Claims
With the assistance of Hometown Health and the City’s health broker, LP, the interpretation of the Plan Document definition is that Nitrous Oxide, is considered a basic/conscious sedation and is not a covered benefit under the Group Health Plan unless the covered member is receiving oral surgery, such as an extraction or root canal. At present, Hometown Health does not pay claims for basic/conscious sedation based on this interpretation unless the sedation is included in the cost of the procedure.
Hometown Health provided the following determinations of our current process:
- Basic/conscious sedation, commonly known as Nitrous Oxide or laughing gas, is not covered for procedures such as fillings and crowns and is only covered when there is a cutting experience such as a root canal or extraction.
- Basic/conscious sedation when billed separately from the procedure itself is a non-covered expense not currently covered by the plan.
- Claims are most often billed as moderate/conscious sedation, which is covered under the plan.
- In calendar year 2019, the City’s Group Health Plan received 13 separately billed claims for basic/conscious sedation, even though the procedures likely involved cutting experiences, such as root canals or extractions.
- The cost to the Plan if basic/conscious sedation had been paid on the 13 claims would have been $3,063.
American Dental Association
Human Resources gathered additional information from the American Dental Association (ADA). Pursuant to the ADA definitions and guidelines, Nitrous Oxide may be indicated as medically necessary for the following:
- Ineffective Local Anesthesia
- Individuals with special needs
- Extensive and/or complex services
- Behaviorally challenged or uncooperative individuals
- Management of a severe gag reflex
While not all dentists are legally authorized to administer Nitrous Oxide, dentists and oral surgeons that are authorized commonly recommend Nitrous Oxide for the following:
- Root Canals
- Tooth Extractions
- Dental Implants
- Lengthy Dental Procedures
- Procedures such as fillings and crowns if deemed medically necessary
Hometown Health, LP, and Human Resources determined that the language in the Plan Document was not in keeping with current practices as indicated by the ADA. Additionally, LP helped in determining that when Nitrous Oxide is billed for cutting procedures or when medical necessary, it is considered a covered expense for other local benefit providers.
Based on calendar year 2019 claims, if the definition of dental anesthesia is expanded to include basic/conscious sedation when the sedation is deemed medically necessary, the estimated increased cost to the Plan is $10,500 annually.
There are currently 1710 members on the Group Health Plan. Currently, members receive preventative services (such as cleanings and mouthguards) at no cost. Following a $50.00 deductible, Basic and Major services have an annual dental benefit maximum per member of $3,000. This means that every member on the plan receives a dental allowance of up to $3,000 every year outside of preventative services, which is paid by the City. This plan change would be included in the $3,000 maximum.
Group Health Care Committee Determination
After reviewing all information and discussing the proposed change, the GHCC approved a change to the Plan Document definition for dental anesthesia to include Nitrous Oxide when deemed medically necessary by the dentist or oral surgeon. The proposed new definition reads as follows:
Anesthesia - General anesthesia when administered for oral surgery. Hypnosis and relative analgesia are covered only if the patient is completely anesthetized to a state of unconsciousness as with a general anesthetic. When deemed medically necessary and in accordance with the standards of the American Dental Association, separate charges for pre-medication, local anesthesia, analgesia or basic/conscious sedation are covered.
If City Council approves a change to the Plan Document to reflect coverage for basic/conscious sedation, covered members will receive Nitrous Oxide during dental procedures when deemed medically necessary. Changes will be effective January 1, 2021. No claims billed before the effective date will be retroactively paid.
- City Council may approve the plan changes to the Group Health Plan Document as presented.
- City Council may reject the plan changes and provide direction to the City Manager.
I move to approve changes to the City of Sparks Group Health Plan Document to reflect coverage for basic/conscious sedation during dental procedures when deemed medically necessary, effective January 1, 2021.