CHAPTER 1360. DIAGNOSIS AND TREATMENT AFFECTING TEMPOROMANDIBULAR JOINT
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1360. DIAGNOSIS AND TREATMENT AFFECTING TEMPOROMANDIBULAR
JOINT
Sec. 1360.001. DEFINITION. In this chapter, "temporomandibular
joint" includes the jaw and the craniomandibular joint.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1360.002. APPLICABILITY OF CHAPTER. This chapter applies
only to a group health benefit plan delivered or issued for
delivery in this state that:
(1) provides benefits for dental, medical, or surgical expenses
incurred as a result of a health condition, accident, or
sickness, including:
(A) a group, blanket, or franchise insurance policy or insurance
agreement, a group hospital service contract, or a group evidence
of coverage that is offered by:
(i) an insurance company;
(ii) a group hospital service corporation operating under
Chapter 842;
(iii) a fraternal benefit society operating under Chapter 885;
(iv) a stipulated premium company operating under Chapter 884;
or
(v) a health maintenance organization operating under Chapter
843; and
(B) to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health
benefit plan that is offered by:
(i) a multiple employer welfare arrangement as defined by
Section 3 of that Act;
(ii) an entity not authorized under this code or another
insurance law of this state that contracts directly for health
care services on a risk-sharing basis, including a capitation
basis; or
(iii) another analogous benefit arrangement; or
(2) is offered by an approved nonprofit health corporation that
holds a certificate of authority under Chapter 844.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1360.003. EXCEPTION. This chapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease or another limited benefit;
(B) only for accidental death or dismemberment;
(C) for wages or payments in lieu of wages for a period during
which an employee is absent from work because of sickness or
injury;
(D) as a supplement to a liability insurance policy;
(E) for credit insurance;
(F) only for vision care; or
(G) only for indemnity for hospital confinement;
(2) a Medicare supplemental policy as defined by Section
1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(3) a workers' compensation insurance policy;
(4) a small employer health benefit plan written under Chapter
1501;
(5) medical payment insurance coverage provided under a motor
vehicle insurance policy; or
(6) a long-term care insurance policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that
the policy provides benefit coverage so comprehensive that the
policy is a health benefit plan as described by Section 1360.002.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1360.004. COVERAGE REQUIRED. (a) A health benefit plan
that provides coverage for medically necessary diagnostic or
surgical treatment of conditions affecting skeletal joints must
provide comparable coverage for diagnostic or surgical treatment
of conditions affecting the temporomandibular joint if the
treatment is medically necessary as a result of:
(1) an accident;
(2) a trauma;
(3) a congenital defect;
(4) a developmental defect; or
(5) a pathology.
(b) Coverage required under this section may be subject to any
provision in the health benefit plan that is generally applicable
to surgical treatment, including a requirement for
precertification of coverage.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1360.005. DENTAL SERVICES COVERAGE NOT REQUIRED. (a) This
chapter does not require a health benefit plan to provide
coverage for dental services if dental services are not otherwise
scheduled or provided as part of the coverage provided under the
plan.
(b) A health benefit plan may not exclude from coverage under
the plan an individual who is unable to undergo dental treatment
in an office setting or under local anesthesia due to a
documented physical, mental, or medical reason as determined by
the individual's physician or by the dentist providing the dental
care.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.