senate Bill S1049

2013-2014 Legislative Session

Requires insurance coverage for craniofacial disorders

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Archive: Last Bill Status - In Committee


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Jan 08, 2014 referred to insurance
Jan 09, 2013 referred to insurance

S1049 - Bill Details

See Assembly Version of this Bill:
A6496
Current Committee:
Law Section:
Insurance Law
Laws Affected:
Amd ยงยง3216, 3221 & 4303, Ins L
Versions Introduced in Previous Legislative Sessions:
2011-2012: S139A, A2622A
2009-2010: S6996, A375

S1049 - Bill Texts

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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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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.

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

                                  1049

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                               (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.

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