State

Statute #

Statute Explanation

Insurance Code § 10123.21

As of July 1, 1995, every individual or group policy of disability insurance that provides hospital,

The Contract: General Provisions

medical, or surgical coverage shall, provide coverage for the surgical procedure of covered

conditions directly affecting the upper or lower jawbone, or associated bone joints, if each

procedure is medically-necessary.

Health & Safety Code § 1367.68

Any provision in a health care service plan or contract issued, renewed or delivered after July 1,

Health Care Service Plans: Standards

1995 that excludes coverage for any surgical procedure for any condition directly affecting the

upper or lower jawbone, or associated bone joints, will have no force of effect as to any enrollee if

that provision results in any failure to provide medically-necessary basic health care services to the

enrollee pursuant to the plan's definition of medical necessity.

37 FSA § 627.419(7)

States health insurance policies which provide coverage for any diagnostic or surgical procedure

The Insurance Contract:

involving bones or joints of the skeleton shall not discriminate against coverage for any similar

Construction of Policies

diagnostic or surgical procedure invovling bones or joints of the jaw and facial region if the

procedure or surgery is medically necessary to treat conditions caused by congenital or

developmental deformity, disease or injury.

37 FSA § 627.6515(7)

Provides group, franchise, or blanket health insurance policies issued or delivered outside the state

Group, Blanket, & Franchise Health

from which a resident is provided coverage for any diagnostic or surgical procedure involving bones

Insurance Policies: Out-of-State

or joints of the skeleton, shall not discriminate against coverage for any similar diagnostic or

surgical procedure involving bones or joints of the jaw and facial region if such procedure or surgery

is medically necessary to treat conditions caused by congenital or developmental deformity,

disease or injury.

37 FSA § 627.65735

Provides group, franchise, or blanket health insurance policies issued or delivered

Group, Blanket, & Franchise Health

from which a resident is provided coverage for any diagnostic or surgical procedure involving bones

Insurance Policies: Nondiscrimination of

or joints of the skeleton, shall not discriminate against coverage for any similar diagnostic or

Coverage for Surgical Pocedures

surgical procedure involving bones or joints of the jaw and facial region if such procedure or surgery

is medically necessary to treat conditions caused by congenital or developmental deformity,

disease or injury.

State

Statute #

Statute Explanation

33 GA ST 29-20

Requires individual accident and sickness insurance policies issued or delivered to

Individual Accident & Sickness Insurance

provide medically necessary surgical or nonsurgical treatment for the correction of TMJ

by physicians or dentists profressionally qualified by training and experience. Further

requires policies to provide medically necessary surgery for the correction of functional

deformities of the maxilla and mandible.

33 GA ST 30-14

Requires group or blanket accident and sickness insurance policies issued or delivered

Group or Blanket Accident &

to provide medically necessary surgical or nonsurgical treatment for the correction of

Sickness Insurance

TMJ by physicians or dentists profressionally qualified by training and experience.

Further requires policies to provide medically necessary surgery for the correction of

functional deformities of the maxilla and mandible.

215 ILCS 5/356Q

Requires insurers to offer, for an additional premium, optional coverage for the reasonable and

Accident & Health Insurance

necessary medical treatment of temporomandibular joint disorder and craniomandibular disorder.

Maximum lifetime benefits for TMJ and craniomandibular treatment shall not be less than $2,500.

25 KRS § 304.17-319

Requires health insurance policies which provide coverage on an expense-incurred basis for

Business and Financial Institutions:

surgical or nonsurgical treatment of skeletal disorders to provide coverage for medically necessary

Health Insurance Contracts

procedures relating to TMJ and craniomandibular jaw disorders. Applies to all policies issued,

delivered or renewed after 1/1/91.

25 KRS § 304.18-0365

Requires all group or blanket policies of health insurance which provides coverage on an expense-

Business and Financial Institutions:

incurred basis for surgical or nonsurgical treatment of skeletal disorders shall provide coverage for

Group & Blanket health Insurance

medically necessary procedures relating to TMJ and craniomandibualr jaw disorders.

Applies to all policies issued, delivered or renewed after 1/1/91.

25 KRS § 304.32-1585

Requires all policies of health insurance which provides coverage on an expense-

Business and Financial Institutions:

incurred basis for surgical or nonsurgical treatment of skeletal disroders shall provide coverage for

Nonprofit Hospital, Medical-Surgical,

medically necessary procedures relating to TMJ and craniomandibualr jaw disorders.

Dental & Health Service Corporations

Applies to all policies issued, delivered or renewed after 1/1/91.

State

Statute #

Statute Explanation

25 KRS § 304.38-1937

Requires all contracts or agreements of health care services which provide coverage for surgical or

Business and Financial Institutions:

nonsurgical treatment of skeletal disorders to provide coverage for medically necessary procedures

Health Maintenance Organizations

relating to TMJ and craniomandibular jaw disorders. Applies to all policies issued, delivered or

renewed after 1/1/91.

MSC § 15-821

States insurance policies that provide coverage on a group or individual basis for a diagnostic or

Insurance

surgical procedure involving a bone or joint of the skeletal structure may not exclude or deny coverage

for the same diagnostic or surgical procedure involving a bone or joint of the face, neck, or head

if the procedure is medically necessary to treat a condition caused by a congenital deformity,

disease, or injury.

MSA § 62A.043(3)

Requires all health policies issued or delivered after 8/1/87 to provide coverage for surgical and

Accident & Health Insurance:

nonsurgical treatment of TMJ and craniomandibular disorders.

Dental Procedures and Coverage of Podiatry

83 MS Code of 1972 § 9-45

Requires all policies issued, delivered or renewed after 1/1/91 to specifically offer coverage for

Accident, Health & Medicare

diagnostic and surgical treatment of TMJ and craniomandibular disorders. Requires coverage for

Supplement Insurance

diagnostic services and surgery to be the same as that for treatment to any other joint in the body

and shall apply if the treatment is administered or prescribed by a physician or dentist. The

minimum lifetime coverage for TMJ and craniomandibular treatment shall be no less than $5,000.

58 NCGSA § 3-121

Prohibits discrimination, in any health benefit plan, against coverage of procedures involving bones

Insurance

or joints of the jaw, face or head. Authorizes therapeutic procedures to include splinting and use

of intraoral prosthetic appliances to reposition the bones.

26.1 NDCC 36-09.3

Requires all health, medical, hospitalization or accident and sickness insurance policies may not

Accident & Health Insuurance

be issued, renewed or delivered after 1/1/91 unless the policy specifically provides coverage for

surgical and nonsurgical treatment of TMJ and craniomandibular disorders. Benefits for coverage

may be limited to a lifetime maximum of $10,000 per person for surgery, and $2,500 for

nonsurgical treatment.

State

Statute #

Statute Explanation

54 NDCC 52.1-.4.6

Requires the board to provide coverage under either a contract for insurance or under a self-

Uniform Group Insurance Program

insurance plan for coverage for surgical and nonsurgical treatment of TMJ and craniomandibular

disorders. Benefits for coverage may be limited to a lifetime maximum of $10,000 per person for

surgery, and $2,500 for nonsurgical treatment.

59A NMSA § 16-13.1

Requires all health insurance policies issued or delivered in the state to provide coverage for

Trade Practices & Frauds

surgical and nonsurgical treatment of TMJ and craniomandibular disorders.

57 NRS 689A.0465

Requires no policy of health insurance may be delivered or issued for delivery if it contains an

Individual Health Insurance

exclusion of coverage of treatment of TMJ. Holds insurers may limit liability on treatment to:

Required Provisions

1.) No more than 50% of the usual and customary charges for treatment actually received by an

insured; and 2.) Treatment which is medically necessary.

57 NRS 689B.0379

Requires no policy of group health insurance may be delivered or issued for delivery if it contains an

Group & Blanket Health Insurance

exclusion of coverage of treatment of TMJ. Holds insurers may limit liability on treatment to:

Group Policies

1.) No more than 50% of the usual and customary charges for treatment actually received by an

insured; and 2.) Treatment which is medically necessary.

57 NRS 695C.1755

Requires no health maintenance organization policies may be delivered or issued for delivery if it

Health Maintenance Organizations

contains an exclusion of coverage of treatment of TMJ. Holds insurers may limit liability on

treatment to: 1.) No more than 50% of the usual and customary charges for treatment actually

received by an insured; and 2.) Treatment which is medically necessary.

Department of Commerce &

States an accident and health policy must cover treatment of TMJ by a licensed dentist when such

Insurance Bulletin

treatment could also be performed by a physician. The Department also adopted the ADA

categorization of TMJ treatment into Phase I and Phase II treatment. Further maintains that

exclusion of TMJ in a major medical policy will not be permitted nor will any exclusion of

treatment by a dentist.

1 Insurance Code of 1951 21.53A

Requires each health benefit plan delivered or issued that provides benefits for the medically

Insurance Code

necessary diagnostic or surgical treatment of skeletal joints must provide comparable coverage

for the medically necessary diagnostic or surgical treatment of conditions affecting the

temporomandibular joint.

State

Statute #

Statute Explanation

38.2 VSA § 3418.2

Requires insurance policies issued, renewed or delivered for diagnostic and surgical treatment

Insurance

involving any bone or joint of the skeletal structure after 4/1/95 to include coverage for diagnostic

and surgical treatment involving any bone or joint of the head, neck, face or jaw and may not

impose limits that are more restrictive than limits on coverage applicable to treatment of any bone

or joint of the skeletal structure if treatment is medically necessary.

8 VSA § 4089g

States health plans shall provide coverage for diagnosis and medically necessary treatment,

Banking and Insurance

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. Further states the 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.

48 RCWA § 48.21.320

Provides a group disability policy entered into or renewed after 12/31/89, shall offer

Group or Blanket Diability Insurance

optional coverage for the treatment of TMJ.

48 RCWA § 48.44.460

Provides a group health care service contract entered into or renewed after 12/31/89,

Health Care Services

shall offer optional coverage for the treatment of TMJ.

48 RCWA § 48.46.530

Provides a health maintenance agreement entered into or renewed after 12/31/89, shall

Health Maintenance Organizations

offer optional coverage for the treatment of TMJ.

WSA 632.895(11)

Provides every disability insurance policy and every self-insured health plan that provides coverage

Insurance Contracts in Specific Lines

of any diagnostic or surgical procedure invovling a bone, joint, muscle or tissue shall provide

coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment for

the correction of temporomandibular disorders if: 1.) The condition is caused by congenital,

developmental or acquired deformity, disease or injury; and 2.) the procedure or device is

reasonable and appropriate for the diagnosis or treatment of the condition; and 3.) The purpose of

the procedure or device is to control or eliminate infection, pain, disease or dysfunction.

Diagnostic procedures and medically necessary nonsurgical treatment for the correction of

temporomandibular disorders may not exceed $1,250 annually. Prior authorization may be

requried by the health-plans or self-insured health plans for treatment.

State

Statute #

Statute Explanation

WSA 609.78

Provides Limited service health organizations, preferred provider plans and managed care plans are

Managed Care Plans

subject to ST 632.895

33 WVA § 16-3f

Requires the insurance commissioner to develop standards regarding TMJ and craniomandibular

Group Accident & Sickness Insurance

disorders and to require all health insurers to make this coverage to policyholders. Further states

The regulations shall be developed by the insurance commissioner with the advice of a six-member

panel to be appointed by the commissioner. Such panel shall consist of a general practicing

dentist who shall be recommended by the West Virginia Dental Association, an oral and

maxillofacial surgeon who shall be recommended by the West Virginia Society for Oral and

Maxillofacial Dentists, a physician who shall be recommended by the West Virginia State Medical

Association, a member from a Health Services Corporation who shall be recommended by the

Health Services Corporation in this state, a member representing commercial health insurers who

shall be recommended by the association representing accident and sickness insurance, and a

representative of the Public Employees Insurance Association.