Bill S1049-2013

Requires insurance coverage for craniofacial disorders

Requires insurance coverage under health insurance plans for diagnosis and treatment of craniofacial disorder; provides a referral from a health care provider under contract with the policy may be required.

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  • Jan 8, 2014: REFERRED TO INSURANCE
  • Jan 9, 2013: REFERRED TO INSURANCE

Memo

BILL NUMBER:S1049

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 30 to section 3216(i), a new paragraph 19 to section 3221(k) and a new subsection (jj) 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.113A/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 S.139A/A.2622A of 2011/2012; Referred to Insurance

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.


Text

STATE OF NEW YORK ________________________________________________________________________ 1049 2013-2014 Regular Sessions IN SENATE (PREFILED) January 9, 2013 ___________
Introduced by Sen. MAZIARZ -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance 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 30 to read as follows: (30)(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 19 to read as follows: (19)(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 (jj) to read as follows: (JJ)(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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