Requires insurance coverage for craniofacial disorders

Title of bill

An act to amend the insurance law, in relation to health insurance coverage for craniofacial disorders

Purpose

To require health insurance policies providing coverage for physician services, major medical or similar comprehensive-type coverage to cover the diagnosis and treatment of temporomandibular joint disorder.

Summary of provisions

Amends the insurance law by adding a new paragraph 25(A) to section 3216(i), a new paragraph 15 (A) to section 3221(k) and a new subsection (ff) to section 4303 to require every individual, group and managed care health policy and plan which provides medical coverage that includes physician services in a physician's office, or major medical, or similar comprehensive-type coverage to provide coverage for the diagnosis and treatment of temporomandibular joint disorder. Such coverage shall include orthodontic and dental treatment necessary to treat and repair all damage traceable to such temporomandibular joint disorder. The coverage may be subject to annual deductibles and coinsurance as deemed appropriate.

Justification

A temporomandibular joint disorder, or TMJ, is a collection of medical and dental conditions related to the complex jaw joint (temporomandibular joint). It can be precipitated by trauma, arthritis, tumors or by long-term stress that causes clenching of the jaw or grinding of the teeth. Whatever the precipitating factor, the bones of the joint and the muscles that open, close and chew become out of sync and result in pain, discomfort, limited range of movement, collapse of bite, wearing of the teeth, headache and speech impediment as well as many other common problems that every other malfunctioning joint in the body is capable of creating.

While TMJ is ultimately a disorder affecting the TM joint, it is treated by a variety of therapies ranging from massage, physical therapy, craniosacral therapy, acupuncture, orthodontic appliances to surgery. The disorder also may be the direct cause of damage to the teeth, which may be repaired or replaced by dental or orthodontic work in prosthesis. Unfortunately, many sufferers find that TMJ diagnosis and treatment falls into a gray area between medical and dental insurance coverage. This legislation would resolve this impasse in favor of regarding TMJ as a disorder of the joint, categorizing it as medical in nature and covered by medical insurance.

Legislative history

S.4558A/A.9596 of 2003/04; Referred to Senate Insurance Committee S.113-A/A.1175 of 2005/06; Amended and Recommended to Senate Insurance Committee S.502 of 2007 Referred to Senate Insurance Committee S.502 of 2008 Referred to Senate Insurance Committee

Fiscal implications

None to the state.

Effective date

This act shall take effect on the first of January next succeeding the date on which it shall have become law.