Third Party Coverage
Associated medical cost laws refer to the requirement that medical plans pay for hospitalization and related medical expenses, such as the administration of general anesthesia, when dental treatment is best performed in the hospital (some state laws allow payment for medical expenses incurred when treatment is performed in the dental office).
Some states have adopted legislation requiring health insurance policies issued within the state to include coverage for the diagnosis and treatment of temporomandibular (TMD) joint disorders and craniomandibular (CMD) disorders on the same basis as other joint disorders. Because TMD is a significant health condition requiring intervention by a licensed dentist and/or physician, insurance companies are strongly encouraged to offer and coordinate benefit coverage for diagnosis and treatment of temporomandibular bone and joint disorders.
- 2009 ADA Resolution 59H - Maximum Fees for Non-Benefitted Services
The American Dental Association encourages constituent dental societies to work for the passage of state legislation to prohibit insurance plans from applying [contract provisions that establish fee limits for non-scheduled dental services]. Dental insurers have begun to limit fees a contracted dentist may charge for services the insurers do not cover. Many state dental societies have filed bills that would prevent insurers from capping fees in this manner. The ADA stands ready to assist state dental societies wishing to enact laws to protect non-covered services.
- Coverage for Treatment of Temporomandibular Joint Dysfunction - ADA Policy (1989:549)
The American Dental Association encourages all third-party payers to offer benefit coverage for diagnosis and treatment of bone and joint disorders without discrimination, and that all third-party payers coordinate the coverage between medical and dental plans to eliminate any disparity in benefits coverage and reimbursement for such disorders.
- 2006 ADA Resolution 58H - Insurance Benefits for Necessary Dental Treatment of Certain Medical Conditions
Directs the ADA to seek changes in federal statutes dealing with ERISA, and urges constituent dental societies to advocate for state laws requiring that dental treatment, which is integral to the treatment of a diagnosed medical disease, be afforded coverage under the third-party medical payer’s contract.
- 2006 ADA Resolution 60H - Medically Necessary Care Consensus Statement
Calls for the ADA to develop a consensus statement by working with national medical associations and dental specialty organizations that validates the need for medical insurance coverage for medically necessary services associated with dental treatment, especially for care for children, the elderly and patients with disabilities.
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