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Bill

S 10606

Relates to insurance coverage for bruxism diagnosis and treatment

2025 Regular Session Introduced by Joe Addabbo

The bill requires private, group, medical, and Medicaid plans to cover bruxism diagnosis and treatment deemed medically necessary, including guards, with protections against limits

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Bill Summary · S 10606

Summary of Bill S.10606 (2025-2026) – New York

Purpose and Intent

  • This bill aims to expand insurance coverage for the diagnosis and treatment of bruxism (teeth grinding) and related occlusal disorders.
  • It asserts that early diagnosis and preventative treatment can reduce costly dental procedures and prevent oral health disparities, especially among low-income individuals, Medicaid recipients, people with disabilities, and underserved minority communities.

Key Provisions

1) Insurance Coverage Across Private Dental Policies (Section 2)

  • Adds a new paragraph to the insurance law requiring every policy that covers dental services to also cover bruxism diagnosis and treatment when deemed medically necessary by a licensed dentist.
  • Coverage components include:
    • Clinical evaluation and screening
    • Diagnosis
    • Treatment planning
    • Follow-up monitoring
    • Custom-fabricated occlusal guards or appliances
  • Protections and standards:
    • Insurers may not deny coverage for a prescribed occlusal guard solely because the treatment is preventative.
    • Coverage cannot be subject to annual or lifetime limits less favorable than those for other medically necessary dental services.
    • New regulations may be issued by the Superintendent of Financial Services to establish medical necessity standards and utilization review.

2) Group/ Blanket Accident and Health Policies (Section 3)

  • Mirrors the private dental policy provisions for group or blanket accident and health policies:
    • Requires coverage for bruxism diagnosis and treatment when medically necessary.
    • Includes same coverage elements (evaluation, diagnosis, planning, follow-up, occlusal guards).
    • Prohibits denial of preventive-focused occlusal guards.
    • Applies non-discriminatory coverage limits relative to other medically necessary dental services.
    • Allows DFS to promulgate implementing rules, including medical necessity and utilization review standards.

3) Medical Expense Indemnity, Hospital Service, and Health Service Corporations (Section 4)

  • Adds a new subsection to require contracts that provide dental coverage to cover bruxism diagnosis and treatment when medically necessary.
  • Coverage components and protections are aligned with the sections above (evaluation, diagnosis, planning, follow-up, occlusal guards).
  • Prohibits denial of preventive-oriented occlusal guards.
  • Ensures no less favorable annual/lifetime limits than other medically necessary dental services.
  • DFS may issue implementing rules and guidelines.

4) New York State Medicaid/FHP-Style Coverage (Section 5)

  • Adds a new paragraph to the social services law to require care and services for bruxism diagnosis and treatment when medically necessary by a licensed dentist.
  • Coverage components include evaluation, diagnosis, planning, follow-up, and custom occlusal guards.
  • Commissioner authority to promulgate regulations, including standards for medical necessity and utilization review.
  • Special priority for access to preventive treatment for:
    • Low-income individuals
    • Individuals with developmental or intellectual disabilities
    • Individuals with neurological conditions related to bruxism
    • Communities with significant oral health disparities

Study and Reporting (Section 6)

  • Requires the Department of Health and the Department of Financial Services to study the impact of expanded bruxism coverage.
  • Focus areas include:
    • Preventive dental outcomes
    • Tooth loss prevention
    • Utilization of restorative procedures
    • Oral health disparities
  • The study report must be submitted to the Governor and Legislature within three years of the act’s effective date.

Effective Date and Applicability (Section 7)

  • Takes effect 180 days after becoming law.
  • Applies to policies and contracts issued, renewed, modified, or amended on or after that effective date.

Affected Parties

  • Insurers and insurers’ policyholders (private dental, group/blanket accident and health, medical expense indemnity, hospital/health service corporations)
  • Individuals covered under these policies, including:
    • General population with dental coverage
    • Medicaid recipients and other publicly funded plans
    • Low-income and underserved communities (targeted by policy provisions and regulatory priority)
  • Dental and medical professionals (licensed dentists) who determine medical necessity
  • State regulatory agencies (DFS and DOH) responsible for rulemaking and oversight

Potential Impacts

  • Increased access to coverage for bruxism diagnosis and treatment, including preventive measures like occlusal guards.
  • Reduction in long-term costs from preventive care potentially lowering needs for crowns, implants, dentures, and other restorative procedures.
  • Alignment of coverage with medical necessity standards to reduce coverage barriers.
  • Expanded protections against caps or denials for preventive bruxism treatment.
  • Data-driven assessment of impact on preventive outcomes and health disparities through a mandated study.

Notes

  • The bill emphasizes medical necessity as determined by a licensed dentist.
  • Requires promulgation of rules/regulations by the Superintendent of Financial Services and by the commissioners (DOH and DFS) for implementation.
  • The measure explicitly addresses health equity by prioritizing access for vulnerable populations.

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

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