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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S1049-2013 Actions

• Jan 9, 2013: REFERRED TO INSURANCE

S1049-2013 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.

S1049-2013 Text

                      S T A T E   O F   N E W   Y O R K
  ________________________________________________________________________

                                    1049

                         2013-2014 Regular Sessions

                              I N  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

   EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                        [ ] is old law to be omitted.
                                                             LBD02286-01-3

 S. 1049                             2

  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.