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Bill

A 11517

Relates to insurance coverage for bruxism diagnosis and treatment

2025 Regular Session

Requires comprehensive insurance coverage for bruxism diagnosis, planning, treatment, and custom occlusal guards across applicable policies, with protections against preventive-den

REFERRED TO INSURANCE
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Bill Summary · A 11517

Overview

  • Bill: A11517 (New York, 2025-2026 Session)
  • Title: Relates to insurance coverage for bruxism diagnosis and treatment
  • Status: Introduced May 28, 2026; referred to the Committee on Insurance
  • Purpose: Require comprehensive insurance coverage for the diagnosis and treatment of bruxism (teeth grinding) and related occlusal disorders, including custom occlusal guards, across various types of health and dental policies; emphasize medically necessary care and expand access, especially for underserved populations.

Main purpose and intent

  • Recognizes bruxism as a serious oral health condition that can lead to tooth fracture, enamel erosion, temporomandibular joint disorders, chronic pain, sleep disruption, and irreversible tooth loss if untreated.
  • Aims to promote preventive oral healthcare by ensuring meaningful reimbursement and coverage for bruxism diagnosis and treatment in order to reduce costly restorative procedures later.
  • Seeks to remove barriers to access by prohibiting insurer denials based solely on the treatment being preventive and by eliminating onerous coverage limitations.

Key provisions and changes

Insurance coverage requirements (dental policies)

  • Applies to all policies that provide coverage or reimbursement for dental services.
  • Coverage must include:
    • Diagnosis and treatment of bruxism and related occlusal disorders when medically necessary (confirmed by a licensed dentist).
    • Clinical evaluation and screening.
    • Diagnosis, treatment planning, follow-up monitoring.
    • Custom-fabricated occlusal guards or appliances prescribed for bruxism treatment.
  • Prohibits denial of coverage for a prescribed occlusal guard on the basis that the treatment is preventive.
  • Coverage cannot have annual or lifetime limits more restrictive than those for other medically necessary dental services.
  • The New York Superintendent of Financial Services may establish rules to implement medical necessity standards and utilization review.

Expanded applicability to other health coverage

  • Group or blanket accident and health policies that cover dental services must provide the same bruxism-related coverage (diagnosis, treatment, and related services) when medically necessary.
  • Mirrors the same sub-items as above (evaluation, diagnosis, planning, follow-up, occlusal guards).
  • Same protections against denying coverage for preventive occlusal guard treatment and against unfavorable annual/lifetime limits.
  • FS Superintendent may issue implementing rules, including medical necessity and utilization review guidelines.

Insurance contract types covered

  • Applies to:
    • Medical expense indemnity corporations
    • Hospital service corporations
    • Health service corporations
    • All such contracts providing dental coverage

Social services law enhancements

  • Adds a new subdivision (f-1) to provide public assistance coverage for bruxism diagnosis and treatment when medically necessary, including:
    • Clinical evaluation, diagnosis, treatment planning, follow-up monitoring, and custom occlusal guards.
  • Commissioner authority to implement rules, with emphasis on prioritizing access for:
    • Low-income individuals
    • Individuals with developmental or intellectual disabilities
    • Individuals with neurological conditions associated with bruxism
    • Communities facing significant oral health disparities

Policy analysis requirement

  • Requires the Department of Health and Department of Financial Services to study the impact of expanded bruxism coverage on:
    • Preventive dental outcomes
    • Tooth loss prevention
    • Utilization of restorative procedures
    • Oral health disparities
  • Report due to the Governor and Legislature within three years of the act’s effective date.

Effective date

  • Takes effect 180 days after enactment.
  • Applies to policies/contracts issued, renewed, modified, or amended on or after the effective date.

Affected parties and potential impact

  • Individuals with bruxism, especially those in low-income, disabled, or underserved communities, may gain access to broader coverage for diagnosis, prevention, and treatment.
  • Dentists and dental practices could see improved reimbursement for bruxism-related services, including occlusal guards and treatment planning.
  • Insurance companies and health service/indemnity organizations would need to adjust policy language, coverage determinations, and utilization review practices to align with the new requirements.
  • State agencies (Department of Health and Department of Financial Services) would implement regulations and monitor compliance; a formal impact study would inform future policy decisions.

Procedural and timeline notes

  • Enactment timeline:
    • Referred to Insurance Committee upon introduction (May 28, 2026).
    • Act takes effect 180 days after it becomes law.
    • Applies to policies/contracts issued, renewed, modified, or amended on or after the effective date.
  • Study requirement:
    • A mandatory comparative impact study by the Department of Health and Department of Financial Services, due within three years of the act’s effective date.

Summary

A11517 would codify comprehensive coverage for bruxism diagnosis and treatment across dental and certain health insurance policies, mandating medically necessary evaluation, diagnosis, planning, monitoring, and occlusal guards, with protections against preventive-only denials and restrictive benefit limits. It also extends similar requirements to public assistance and requires regulatory rulemaking and a state-commissioned impact study, with special emphasis on improving access for underserved populations. The act would take effect six months after passage and apply to newer or amended contracts/policies.

Compiled from official sources — confirm details with the bill’s official record.

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