AN ACT Relating to health insurance; adding a new section to chapter 48.21 RCW; adding a new section to chapter 48.44 RCW; adding a new section to chapter 48.46 RCW; adding a new section to chapter 18.71 RCW; adding a new section to chapter 18.32 RCW; adding a new section to chapter 48.02 RCW; and creating a new section.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION. Sec. 1. The legislature finds that more and more medical plan carriers, including commercial insurance companies, health care service contractors, and health maintenance organizations, are not covering temporomandibular joint disorder diagnosis and treatment or are insisting that the condition be covered under dental plans. Likewise, some dental plan carriers have stated that the condition should be covered under medical plans. Current trends indicate that plans of both types are incorporating specific exclusions for the treatment of this disorder. The result has been an undue hardship on temporomandibular joint disorder patients both financially and physically.

NEW SECTION. Sec. 2. A new section is added to chapter 48.21 RCW to read as follows:

Any group disability insurance contract, which provides medical or dental coverage, issued, delivered, or renewed after January 1, 1990, shall offer optional coverage for medically necessary surgical and nonsurgical treatment, including outpatient treatment, of temporomandibular joint disorder. Coverage shall comply with rules adopted by the medical disciplinary board under section 5 of this act, the dental disciplinary board under section 6 of this act, and the insurance commissioner under section 7 of this act.

Carriers of group contracts offering coverage under this section for temporomandibular joint disorder shall provide data to the insurance commissioner concerning the availability, cost, utilization, and nature of coverage offered and information on the characterizations by the carrier of temporomandibular joint disorder treatments for claims payment. Carriers shall furnish such data and any other nonproprietary information the commissioner requires in rule to facilitate a review and analysis of coverage for temporomandibular joint disorder under this section.

Carriers of group contracts offering coverage under this section for temporomandibular joint disorder shall provide a means in the contract for prompt resolution of disputes regarding coverage, at no cost to the individuals covered under the contracts. Carriers shall maintain records of the experience of dispute resolution programs and shall provide such information to the commissioner upon request.

NEW SECTION. Sec. 3. A new section is added to chapter 48.44 RCW to read as follows:

Any group health care service contract, which provides medical or dental coverage, entered into or renewed after January 1, 1990, shall offer optional coverage for medically necessary surgical and nonsurgical treatment, including outpatient treatment, of temporomandibular joint disorder. Coverage shall comply with rules adopted by the medical disciplinary board under section 5 of this act, the dental disciplinary board under section 6 of this act, and the insurance commissioner under section 7 of this act.

NEW SECTION. Sec. 4. A new section is added to chapter 48.46 RCW to read as follows:

Any group health maintenance agreement, which provides medical or dental coverage, entered into or renewed after January 1, 1990, shall offer optional coverage for medically necessary surgical and nonsurgical treatment, including outpatient treatment, of temporomandibular joint disorder. Coverage shall comply with rules adopted by the medical disciplinary board under section 5 of this act, the dental disciplinary board under section 6 of this act, and the insurance commissioner under section 7 of this act.

NEW SECTION. Sec. 5. A new section is added to chapter 18.71 RCW to read as follows:

The medical disciplinary board shall promulgate rules defining medically necessary treatment for temporomandibular joint disorder and shall establish protocols for the diagnosis and surgical and nonsurgical treatment of temporomandibular joint disorders. The board shall consult with the dental disciplinary board and shall review and update the definitions and protocols periodically. The definitions and practice protocols shall be based upon accepted treatment standards of practice, except that, when a temporomandibular joint disorder results from a traumatic injury, any needed dental restoration work shall be considered medically necessary.

NEW SECTION. Sec. 6. A new section is added to chapter 18.32 RCW to read as follows:

The dental disciplinary board shall promulgate rules defining medically necessary treatment for temporomandibular joint disorder and shall establish protocols for the diagnosis and surgical and nonsurgical treatment of temporomandibular joint disorders. The board shall consult with the medical disciplinary board and shall review and update the definitions and protocols periodically. The definitions and practice protocols shall be based upon accepted treatment standards of practice, except that, when a temporomandibular joint disorder results from a traumatic injury, any needed dental restoration work shall be considered medically necessary.

NEW SECTION. Sec. 7. A new section is added to chapter 48.02 RCW to read as follows:

The insurance commissioner in consultation with the medical disciplinary board and the dental disciplinary board shall establish in rule minimum standard benefits, terms, definitions, conditions, limitations, and benefit levels and provide for reasonable deductibles and co-payments, for insurance coverage for temporomandibular joint disorders offered pursuant to section 2, 3, or 4 of this act.

The insurance commissioner shall report to the legislature no later than July 1, 1991, on insurance coverage for temporomandibular joint disorders offered pursuant to section 2, 3, or 4 of this act.