Amd §§3216, 3221 & 4303, Ins L; amd §365-a, Soc Serv L
Requires policies which provide dental coverage to provide coverage for bruxism diagnosis and treatment, including the cost of occlusal guards; requires medicaid and HMO coverage.
STATE OF NEW YORK
________________________________________________________________________
11517
IN ASSEMBLY
May 28, 2026
___________
Introduced by COMMITTEE ON RULES -- (at request of M. of A. Lavine) --
read once and referred to the Committee on Insurance
AN ACT to amend the insurance law and the social services law, in
relation to insurance coverage for bruxism diagnosis and treatment
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Legislative findings. The legislature hereby finds and
2 declares that Bruxism is a serious oral health condition that may result
3 in tooth fracture, enamel erosion, temporomandibular joint disorders,
4 chronic pain, sleep disruption, and irreversible tooth loss when left
5 untreated. Early diagnosis and preventative treatment of bruxism
6 substantially reduces the need for costly restorative dental procedures,
7 including crowns, implants, dentures, and oral surgery. Current dental
8 reimbursement practices frequently fail to adequately compensate
9 dentists for the evaluation, diagnosis, and treatment planning associ-
10 ated with bruxism and related occlusal disorders, thereby discouraging
11 preventative intervention. Many dental insurance policies nominally
12 provide coverage for occlusal guards while imposing reimbursement limi-
13 tations, utilization barriers, or medical necessity requirements that
14 render such coverage inaccessible in practice. Low-income individuals,
15 Medicaid recipients, individuals with disabilities, and underserved
16 minority communities disproportionately experience barriers to preventa-
17 tive oral healthcare and are more likely to suffer preventable dental
18 deterioration and tooth loss due to untreated bruxism. It is therefore
19 in the public interest to promote preventative oral healthcare by
20 requiring meaningful reimbursement and coverage for the diagnosis and
21 treatment of bruxism and related occlusal disorders.
22 § 2. Subsection (i) of section 3216 of the insurance law is amended by
23 adding a new paragraph 42 to read as follows:
24 (42) (A) Every policy which provides coverage or reimbursement for
25 dental services shall provide coverage or reimbursement for the diagno-
26 sis and treatment of bruxism and related occlusal disorders when deter-
27 mined to be medically necessary by a licensed dentist.
28 (B) Such coverage shall include reimbursement for:
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD15988-01-6
A. 11517 2
1 (i) clinical evaluation and screening;
2 (ii) diagnosis;
3 (iii) treatment planning;
4 (iv) follow-up monitoring; and
5 (v) custom-fabricated occlusal guards or appliances prescribed for the
6 treatment of diagnosed bruxism or related occlusal disorders.
7 (C) No insurer shall deny coverage for a prescribed occlusal guard
8 solely on the basis that the treatment is preventative in nature.
9 (D) Coverage provided pursuant to this paragraph shall not be subject
10 to annual or lifetime limitations that are less favorable than those
11 imposed on other medically necessary dental services.
12 (E) The superintendent of financial services may promulgate rules and
13 regulations necessary to implement the provisions of this paragraph,
14 including standards relating to medical necessity and utilization
15 review.
16 § 3. Subsection (l) of section 3221 of the insurance law is amended by
17 adding a new paragraph 24 to read as follows:
18 (24) (A) Every group or blanket accident and health insurance policy
19 issued or issued for delivery in this state which provides coverage or
20 reimbursement for dental services shall provide coverage or reimburse-
21 ment for the diagnosis and treatment of bruxism and related occlusal
22 disorders when determined to be medically necessary by a licensed
23 dentist.
24 (B) Such coverage shall include reimbursement for:
25 (i) clinical evaluation and screening;
26 (ii) diagnosis;
27 (iii) treatment planning;
28 (iv) follow-up monitoring; and
29 (v) custom-fabricated occlusal guards or appliances prescribed for the
30 treatment of diagnosed bruxism or related occlusal disorders.
31 (C) No insurer shall deny coverage for a prescribed occlusal guard
32 solely on the basis that the treatment is preventative in nature.
33 (D) Coverage provided pursuant to this paragraph shall not be subject
34 to annual or lifetime limitations that are less favorable than those
35 imposed on other medically necessary dental services.
36 (E) The superintendent of financial services may promulgate rules and
37 regulations necessary to implement the provisions of this paragraph,
38 including standards relating to medical necessity and utilization
39 review.
40 § 4. Section 4303 of the insurance law is amended by adding a new
41 subsection (yy) to read as follows:
42 (yy) (1) Every contract issued by a medical expense indemnity corpo-
43 ration, a hospital service corporation or a health service corporation
44 which provides coverage or reimbursement for dental services shall
45 provide coverage or reimbursement for the diagnosis and treatment of
46 bruxism and related occlusal disorders when determined to be medically
47 necessary by a licensed dentist.
48 (2) Such coverage shall include reimbursement for:
49 (A) clinical evaluation and screening;
50 (B) diagnosis;
51 (C) treatment planning;
52 (D) follow-up monitoring; and
53 (E) custom-fabricated occlusal guards or appliances prescribed for the
54 treatment of diagnosed bruxism or related occlusal disorders.
55 (3) No insurer shall deny coverage for a prescribed occlusal guard
56 solely on the basis that the treatment is preventative in nature.
A. 11517 3
1 (4) Coverage provided pursuant to this paragraph shall not be subject
2 to annual or lifetime limitations that are less favorable than those
3 imposed on other medically necessary dental services.
4 (5) The superintendent of financial services may promulgate rules and
5 regulations necessary to implement the provisions of this paragraph,
6 including standards relating to medical necessity and utilization
7 review.
8 § 5. Subdivision 2 of section 365-a of the social services law is
9 amended by adding a new paragraph (f-1) to read as follows:
10 (f-1) (i) care and services for the diagnosis and treatment of bruxism
11 and related occlusal disorders when determined to be medically necessary
12 by a licensed dentist.
13 (ii) Such coverage shall include reimbursement for:
14 (A) clinical evaluation and screening;
15 (B) diagnosis;
16 (C) treatment planning;
17 (D) follow-up monitoring; and
18 (E) custom-fabricated occlusal guards or appliances prescribed for the
19 treatment of diagnosed bruxism or related occlusal disorders.
20 (iii) The commissioner may promulgate rules and regulations necessary
21 to implement the provisions of this paragraph, including standards
22 relating to medical necessity and utilization review. In promulgating
23 such regulations, the commissioner shall prioritize access to preventa-
24 tive treatment for:
25 (A) low-income individuals;
26 (B) individuals with developmental or intellectual disabilities;
27 (C) individuals with neurological conditions associated with bruxism;
28 and
29 (D) communities experiencing significant oral health disparities;
30 § 6. 1. The department of health and department of financial services
31 shall study the impact of expanded bruxism diagnosis and treatment
32 coverage on:
33 a. preventative dental outcomes,
34 b. tooth loss prevention,
35 c. utilization of restorative dental procedures,
36 d. and oral health disparities.
37 2. The report required by this section shall be submitted to the
38 governor and legislature within three years of the effective date of
39 this act.
40 § 7. This act shall take effect on the one hundred eightieth day after
41 it shall have become a law and shall apply to policies and contracts
42 issued, renewed, modified, altered or amended on or after such effective
43 date.
