State of Wisconsin Fact Sheet of Mandated
Benefits for TMJ Disorders

This information was taken from pages six and seven of the State of Wisconsin Office of the Commissioner of Insurance Fact Sheet on Mandated Benefits in Health Insurance Policies located at:

TMJ Disorders

All groups and individual disability insurance policies issued or renewed on or after January 1, 1998 that provide coverage of any diagnostic or surgical procedure involving a bone, joint, muscle, or tissue are required to provide coverage for diagnostic procedures and medically necessary surgical or nonsurgical treatment (including prescribed intraoral splint therapy devices) for the correction of temporomandibular (TMJ) disorders.

This applies to both groups and individual policies, except dental-only and Medicare supplement policies, including HMOs, PPPs and LSHOs, and every self-funded county, municipality and school district health plan [ss. 609.78 and 632.895 (11), Wis. Stat.]

All health insurance policies issued or renewed on or after June 17, 1998 may cap coverage of nonsurgical diagnosis and treatment of TMJ at $1,250.00 per year. Plans are permitted to impose a prior authorization requirement on surgical or non surgical TMJ service, but not diagnosis.


State Of WI Mandated Benefits

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