SENATE BILL REPORT

SB 5560

BYSenators von Reichbauer, Wojahn, Johnson, Vognild, Moore, Bauer, Warnke, Smitherman, Rasmussen, Sutherland, Fleming, Stratton, Matson, McMullen and Sellar

Providing for insurance coverage for temporomandibular joint disorders.

Senate Committee on Financial Institutions & Insurance

Senate Hearing Date(s):February 9, 1989; February 14, 1989

Majority Report:  That Substitute Senate Bill No. 5560 be substituted therefor, and the substitute bill do pass.

      Signed by Senators von Reichbauer, Chairman; Johnson, Vice Chairman; Fleming, McCaslin, McMullen, Moore, Rasmussen, Sellar, Smitherman.

Senate Staff:Benson Porter (786-7470)

                  March 1, 1989

AS REPORTED BY COMMITTEE ON FINANCIAL INSTITUTIONS & INSURANCE, FEBRUARY 14, 1989

BACKGROUND:

Insurers are not required to offer or provide coverage for temporomandibular joint (TMJ) disorders.  The TMJ is the hinged joint between the skull and the lower jaw bone. 

TMJ disorders can be accompanied by a variety of symptoms including:  headaches, pain in or around the joint, difficulty in opening the mouth, sticking of the joint, and pain from joint movement associated with eating and speaking.

SUMMARY:

A group disability insurance contract, health care service contract, or group maintenance agreement entered into or renewed after January 1, 1990 must offer optional coverage for treatment of TMJ disorders.  Surgical, nonsurgical and outpatient treatment deemed medically necessary must be covered. 

The Medical and Dental Disciplinary Boards are each to promulgate rules defining "medically necessary" treatments for TMJ disorders and establish protocols for the diagnosis and treatment of these disorders. 

Upon consultation with the Medical and Dental Disciplinary Boards, the Insurance Commissioner is to adopt rules establishing minimum benefits, terms, definitions, and certain other benefit levels.  Reasonable deductibles and copayments are to be permitted. 

The Insurance Commissioner is to deliver a report on the offered insurance coverage for TMJ disorders to the Legislature by January 1, 1991.

EFFECT OF PROPOSED SUBSTITUTE:

Group disability insurers, health care contractors, and health maintenance organizations (HMO) must offer optional temporomandibular joint disorder coverage on group contracts entered into and renewed after December 31, 1989.  If an employer declines the optional coverage, temporomandibular joint coverage still may be included in a basic group contract.

Coverage flexibility is promoted.  The requirement that the Mental and Dental Disciplinary Boards establish rules defining "medically necessary" treatments is deleted.  In addition, the Insurance Commissioner's rule-making authority to immediately establish minimum standard benefits, terms, and conditions is extended to January 1, 1993.  The use of gatekeepers, copayments, and deductibles is allowed.  Instead of consulting with the Medical and Dental Disciplinary Boards in the preparation of rules, the commissioner shall consult with a panel of experts.  The panel shall be comprised of medical and dental experts specializing in temporomandibular joint disorders, an employer purchasing a group policy, and a representative of the insurers, health care contractors, or health maintenance organizations.

If a group disability insurer, health care contractor or HMO offers a group contract to an employer who already offers a self-insured plan not subject to Title 48 RCW, the optional temporomandibular joint coverage may not be offered.

An insurer, health care contractor, or HMO offering medical coverage only may limit coverages to medical treatments.  Similarly, an insurer or health care contractor offering dental coverage only may limit coverages to dental treatments.  A HMO offering medical and dental coverage may not limit benefits to only dental services.

The provisions regarding dispute resolutions are deleted.

Appropriation:    none

Revenue:    none

Fiscal Note:      available

Senate Committee - Testified: Dennis Martin, WSTLA (pro); Nancy Korb, TMJ Support Group (pro); Nila Gillespie, Independent (pro); Luci Phillips, State Health Coordinating Council (pro) Sue Skillings, Independent (pro); Ken Bertrand, Group Health (con); Mel Sorensen, Washington Physicians Service (con); Basil Badley, HIAA and WDS (con); K. Collins Sprague, AWB (con); Dr. Herb Gordon, WSDA, SKKACA; Pam Brotnen, Independent; Mark D. Carlson, private practice (pro); Dr. Dale Gilsdorf (pro); Kathie Pelley (pro)