State

Statute #

 

 

Statute Explanation

 

 

 

 

 

 

 

 

AK

 

 

 

 

Arkansas: TMJ disorders must be treated the same as any other illness or injury and not considered dental work

 

CA

 

 

 

 

 

 

 

 

The Contract: General Provisions

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Code 10123.21

 

 

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

 

 

 

 

 

 

procedure is medically-necessary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CA

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FL

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FL

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FL

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 Procedures

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GA

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GA

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.

 

 

 

 

 

 

 

 

Georgia: Claims for treatment by a physician or dentist for orofacial

 

 

 

 

 

 

 

pain including, but not limited to, Tmj and myofascial pain problems must

 

 

 

 

 

 

be honored under major medical policies of insurers and not-for- profit

 

 

 

 

 

 

service corporations.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

KY

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KY

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KY

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kentucky: All policies and contracts that provide coverage for surgical

 

 

 

 

 

 

or non-surgical treatment of skeletal disorders must provide coverage for

 

 

 

 

 

 

medically necessary procedures relating to TMJ and craniomandibular

 

 

 

 

 

 

disorders.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

KY

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MD

ST

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.

 

 

 

 

 

 

 

 

 

 

 

Maryland: Group and individual insurers and non-profit health-service

 

 

 

 

 

 

plans that provide coverage for diagnostic or surgical procedures

 

 

 

 

 

 

 

involving a bone or a joint of the skeletal structure must provide

 

 

 

 

 

 

 

coverage for the same procedure involving a bone or joint of the face,

 

 

 

 

 

 

neck, or head if medically necessary to treat a congentital deformity,

 

 

 

 

 

 

disease, or injury.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MN

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

 

 

 

 

 

 

 

 

 

 

 

 

 

Minnesota: Insurers, HMO's, and subscriber contracts must provide

 

 

 

 

 

 

 

coverage for treatment of TMJ disorders when adminstered by doctors or

 

 

 

 

 

 

dentists.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MS

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

NC

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ND

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ND

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.

 

 

 

 

 

 

 

 

North Dakota: Coverage of TMJ disorders must be provided in all but

 

 

 

 

 

 

special disease policies. Coveage applies if treatment is administered or

 

 

 

 

 

 

prescribed by a physician, dentist, or surgeon. Benefits my be limited to

 

 

 

 

 

 

a lifetime maimum of $8,000 per person for surgery and $2000 for

 

 

 

 

 

 

 

non-surgical treatment.

 

 

 

 

 

 

NM

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NV

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NV

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NV

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.

 

 

 

 

 

 

Nevada: Legislation prohibits insurance policies and contracts from

 

 

 

 

 

 

 

excluding, either by specific language or settlement practices, coverage

 

 

 

 

 

 

of the temporomandibular joint. Methods of treatment that are recognized

 

 

 

 

 

 

as dental procedures, however, mayb be excluded, and insurers may limit

 

 

 

 

 

 

TMJ benefits to 50% of the usual charges and to treatment that is

 

 

 

 

 

 

 

medically necessary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NM

 

 

 

New Mexico: All insurers must provide coverage for surgical and

 

 

 

 

 

 

 

non-surgical treatment of TMJ and cranosmandibular disorders, subject to

 

 

 

 

 

 

the same conditions, limitations, prior review, and referral procedures

 

 

 

 

 

 

that are applicable to the treatment of any other body joint.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TN

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.

 

 

 

 

 

 

 

 

 

 

Tennessee: Accident and health policies must cover treatment of TMJ

 

 

 

 

 

 

disorders by a dentist when such treatment also could be performed by a

 

 

 

 

 

 

physician.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TX

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.

 

 

 

 

 

 

 

 

 

 

Texas: Orthodontic coverage may not be excluded on grounds that overbite,

 

 

 

 

 

 

overjet, openbite, or arch lenght discrepanies measure less than 4

 

 

 

 

 

 

 

millimeters. Also, HMOs must provide treatment for the tempormandibular

 

 

 

 

 

 

and craniomandibular joints when comparable to disagnostic and /or

 

 

 

 

 

 

surgical treatment of skeletal joints in other parts of the body.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VA

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VT

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.

 

 

 

 

 

 

Vermont: Treatment of TMJ disorders does not come within standard dental

 

 

 

 

 

 

care and treatment exclusion and must be honored under the medical

 

 

 

 

 

 

expense portion of the policy.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WA

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WA

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WA

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.

 

 

 

 

 

 

 

 

Washington: Surgical and non-surgical TMJ benefits must be offered as

 

 

 

 

 

 

optional coverage in medical and dental group insurance contracts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WV

 

 

 

West Virginia: Insurers must make coverage available for TMJ and

 

 

 

 

 

 

 

craniomandibular disorders pursuant to the standards developed by teh

 

 

 

 

 

 

insurance commissioner.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WI

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WI

WSA 609.78

 

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

Managed Care Plans

 

 

subject to ST 632.895

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WV

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.