S139A-2011 Actions

• Jan 13, 2012: PRINT NUMBER 139A
• Jan 13, 2012: AMEND AND RECOMMIT TO INSURANCE
• Jan 4, 2012: REFERRED TO INSURANCE
• Jan 5, 2011: REFERRED TO INSURANCE

S139A-2011 Memo

BILL NUMBER:S139

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 28(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
S.6996 of 2009/2010; 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.

S139A-2011 Text

 S T A T E   O F   N E W   Y O R K
 
 139--A
 2011-2012 Regular Sessions
 I N  SENATE
 (PREFILED)
 January 5, 2011
 
 Introduced  by  Sen. MAZIARZ -- read twice and ordered printed, and when
 printed to be committed to the Committee on Insurance  --  recommitted
 to the Committee on Insurance in accordance with Senate Rule 6, sec. 8
 --  committee  discharged,  bill amended, ordered reprinted as amended
 and recommitted to said committee
 

AN ACT to amend the insurance  law,  in  relation  to  health  insurance
 coverage for craniofacial disorders
 

THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM
 BLY, DO ENACT AS FOLLOWS:

 

Section 1. Subsection (i) of section 3216  of  the  insurance  law  is
 amended by adding a new paragraph 29 to read as follows:

 (29)(A)  EVERY  POLICY  DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE
 WHICH PROVIDES MEDICAL COVERAGE THAT  INCLUDES  COVERAGE  FOR  PHYSICIAN
 SERVICES  IN  A PHYSICIAN'S OFFICE AND EVERY POLICY WHICH PROVIDES MAJOR
 MEDICAL OR SIMILAR COMPREHENSIVE-TYPE COVERAGE  SHALL  PROVIDE  COVERAGE
 FOR  DIAGNOSIS AND MEDICALLY NECESSARY TREATMENT, INCLUDING SURGICAL AND
 NONSURGICAL PROCEDURES, FOR A MUSCULOSKELETAL DISORDER THAT AFFECTS  ANY
 BONE  OR  JOINT IN THE FACE, NECK OR HEAD AND IS THE RESULT OF ACCIDENT,
 TRAUMA, CONGENITAL DEFECT, DEVELOPMENTAL DEFECT, OR  PATHOLOGY.  SUBJECT
 TO  SUBPARAGRAPH  (B) OF THIS PARAGRAPH, THIS COVERAGE SHALL BE THE SAME
 AS THAT PROVIDED UNDER THE HEALTH INSURANCE PLAN FOR  ANY  OTHER  MUSCU
 LOSKELETAL  DISORDER  IN THE BODY AND MAY BE PROVIDED WHEN PRESCRIBED OR
 ADMINISTERED BY A PHYSICIAN OR A DENTIST. THIS PARAGRAPH  SHALL  NOT  BE
 CONSTRUED  TO  REQUIRE COVERAGE FOR DENTAL SERVICES FOR THE DIAGNOSIS OR
 TREATMENT OF DENTAL DISORDERS OR DENTAL  PATHOLOGY  PRIMARILY  AFFECTING
 THE GUMS, TEETH, OR ALVEOLAR RIDGE.
 (B)  A  REFERRAL  FROM  A HEALTH CARE PROVIDER UNDER CONTRACT WITH THE
 POLICY MAY BE REQUIRED.
 

S 2. Subsection (k) of section 3221 of the insurance law is amended by
 adding a new paragraph 18 to read as follows:

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
 [ ] is old law to be omitted.
 LBD01218-02-1
 
       S. 139--A                           2
 (18)(A) EVERY GROUP OR BLANKET POLICY DELIVERED OR ISSUED FOR DELIVERY
 IN THIS STATE WHICH PROVIDES MEDICAL COVERAGE THAT INCLUDES COVERAGE FOR
 PHYSICIAN SERVICES IN A PHYSICIAN'S OFFICE OR MAJOR MEDICAL  OR  SIMILAR
 COMPREHENSIVE-TYPE  COVERAGE  SHALL  PROVIDE  COVERAGE FOR DIAGNOSIS AND
 MEDICALLY NECESSARY TREATMENT, INCLUDING SURGICAL AND NONSURGICAL PROCE
 DURES,  FOR A MUSCULOSKELETAL DISORDER THAT AFFECTS ANY BONE OR JOINT IN
 THE FACE, NECK OR HEAD AND IS THE RESULT OF ACCIDENT, TRAUMA, CONGENITAL
 DEFECT, DEVELOPMENTAL DEFECT, OR PATHOLOGY. SUBJECT TO SUBPARAGRAPH  (B)
 OF  THIS  PARAGRAPH,  THIS  COVERAGE  SHALL BE THE SAME AS THAT PROVIDED
 UNDER THE HEALTH INSURANCE PLAN FOR ANY OTHER  MUSCULOSKELETAL  DISORDER
 IN  THE  BODY  AND  MAY BE PROVIDED WHEN PRESCRIBED OR ADMINISTERED BY A
 PHYSICIAN OR A DENTIST. THIS PARAGRAPH SHALL NOT BE CONSTRUED TO REQUIRE
 COVERAGE FOR DENTAL SERVICES FOR THE DIAGNOSIS OR  TREATMENT  OF  DENTAL
 DISORDERS  OR  DENTAL  PATHOLOGY PRIMARILY AFFECTING THE GUMS, TEETH, OR
 ALVEOLAR RIDGE.
 (B) A REFERRAL FROM A HEALTH CARE PROVIDER  UNDER  CONTRACT  WITH  THE
 POLICY MAY BE REQUIRED.
 

S  3. 

Section  4303  of  the insurance law is amended by adding a new
 subsection (ii) to read as follows:

 (II)(1) A HOSPITAL  SERVICE  CORPORATION,  MEDICAL  EXPENSE  INDEMNITY
 CORPORATION  OR HEALTH SERVICE CORPORATION WHICH PROVIDES MEDICAL COVER
 AGE THAT INCLUDES COVERAGE  FOR  PHYSICIAN  SERVICES  IN  A  PHYSICIAN'S
 OFFICE  OR  MAJOR  MEDICAL  OR SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL
 PROVIDE  COVERAGE  FOR  DIAGNOSIS  AND  MEDICALLY  NECESSARY  TREATMENT,
 INCLUDING  SURGICAL  AND  NONSURGICAL  PROCEDURES, FOR A MUSCULOSKELETAL
 DISORDER THAT AFFECTS ANY BONE OR JOINT IN THE FACE, NECK OR HEAD AND IS
 THE RESULT OF ACCIDENT, TRAUMA, CONGENITAL DEFECT, DEVELOPMENTAL DEFECT,
 OR PATHOLOGY. SUBJECT TO PARAGRAPH TWO OF THIS SUBSECTION, THIS COVERAGE
 SHALL BE THE SAME AS THAT PROVIDED UNDER THE HEALTH INSURANCE  PLAN  FOR
 ANY  OTHER MUSCULOSKELETAL DISORDER IN THE BODY AND MAY BE PROVIDED WHEN
 PRESCRIBED OR ADMINISTERED BY A PHYSICIAN OR A DENTIST. THIS  SUBSECTION
 SHALL  NOT  BE CONSTRUED TO REQUIRE COVERAGE FOR DENTAL SERVICES FOR THE
 DIAGNOSIS OR TREATMENT OF DENTAL DISORDERS OR DENTAL PATHOLOGY PRIMARILY
 AFFECTING THE GUMS, TEETH, OR ALVEOLAR RIDGE.
 (2) A REFERRAL FROM A HEALTH CARE PROVIDER  UNDER  CONTRACT  WITH  THE
 POLICY MAY BE REQUIRED.
 

S  4. This act shall take effect on the first of January next succeed
 ing the date on which it shall have become a law and shall apply to  all
 policies issued, renewed, altered or modified on or after such date.

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