Tmansdc
11-29-2005, 12:04 AM
I want to know because my insurance doesn't and I want to get a temporary insurance plan to cover tmj because I can't afford the payment for surgery/fitting/mouthguard/etc.
I live in Las Vegas, Nevada by the way.
I live in Las Vegas, Nevada by the way.
Sponsor
Tmansdc
11-29-2005, 02:19 AM
I really need to know.
raylp
11-29-2005, 10:28 AM
This is not an easy question to answer. My two cents on it are first to see if your state has a TMJ coverage mandate. Each state is different.
Once you do this, then I would ask questions in writing to an insurance company. See what they cover, and to what extent. You might get a response, not sure.
I had an HMO plan at the time of seeking TMJ coverage. They gave me the biggest runaround of my life. Not a fun ride. I did get approval, out of network, for a surgeon of my choosing, but only after going through a big ordeal. Then I learned more about TMJ and decided to postpone surgery.
This is my opinion of TMJ medicine and insurance: you will likely spend some time going from doctor to doctor looking for someone who is helpful. Then if and when you find them, there will likely still be a mystery to the whole thing, and you will wonder if you are getting the care you seek. That's largely why all of us here are working together to be informed.
Even if this isn't the case in your situation, be prepared for it with insurance.
Not sure if this is answering your question, but I tried. I only have my experience to go from.
There are past postings on insurance. Use the search function of the site to study up.
Once you do this, then I would ask questions in writing to an insurance company. See what they cover, and to what extent. You might get a response, not sure.
I had an HMO plan at the time of seeking TMJ coverage. They gave me the biggest runaround of my life. Not a fun ride. I did get approval, out of network, for a surgeon of my choosing, but only after going through a big ordeal. Then I learned more about TMJ and decided to postpone surgery.
This is my opinion of TMJ medicine and insurance: you will likely spend some time going from doctor to doctor looking for someone who is helpful. Then if and when you find them, there will likely still be a mystery to the whole thing, and you will wonder if you are getting the care you seek. That's largely why all of us here are working together to be informed.
Even if this isn't the case in your situation, be prepared for it with insurance.
Not sure if this is answering your question, but I tried. I only have my experience to go from.
There are past postings on insurance. Use the search function of the site to study up.
Tmansdc
11-30-2005, 01:22 AM
Any second opinions? any sites to look up dental or medical insurances? (not sure which would cover tmj.)
Michelle W
11-30-2005, 03:23 AM
I have been working on this problem for six months. It isn't a one day question. I had to find insurance companies such as Blue Cross/Blue Shield, Aetna, Healthfirst, Principal, and ask them for a coverage booklet to see if they would cover it. It might take me a week to get a person. Then it would take a week to get them to fax me the booklet/policy. You have to look at the exclusions on the policy.
Also, most insurance people are sales people. They are not medical people or nurses and most could not even pronounce tempromandibular joint disorder. They were like huh? What? Sure it is covered and then I would look at the policy to only find it was not. They are sales people wanting to sale you a policy. They don't care if it is covered.
Also, if you do not currently have coverage it will be considered pre-existing and not be covered. You can only get it covered if you go from one group policy to another group policy and have a HIPPA certificate. You can not be uninsured and then go out and buy a private policy. I tried that and it is considered pre-existing.
Just because Aetna covers TMJ in Nebraska does not mean it will cover it in Missouri. Nebraska may be a state in which TMJ is mandated that it be covered where in Missouri it is not mandated that it be covered. Call you State Insurance Commissoner in Nevada and ask if TMJ is covered.
Also, we can't post website links unless they are approved by the moderators. It is against the rules.
Also, most insurance people are sales people. They are not medical people or nurses and most could not even pronounce tempromandibular joint disorder. They were like huh? What? Sure it is covered and then I would look at the policy to only find it was not. They are sales people wanting to sale you a policy. They don't care if it is covered.
Also, if you do not currently have coverage it will be considered pre-existing and not be covered. You can only get it covered if you go from one group policy to another group policy and have a HIPPA certificate. You can not be uninsured and then go out and buy a private policy. I tried that and it is considered pre-existing.
Just because Aetna covers TMJ in Nebraska does not mean it will cover it in Missouri. Nebraska may be a state in which TMJ is mandated that it be covered where in Missouri it is not mandated that it be covered. Call you State Insurance Commissoner in Nevada and ask if TMJ is covered.
Also, we can't post website links unless they are approved by the moderators. It is against the rules.
laskalady
11-30-2005, 02:14 PM
Michelle W- I have a couple of questions for you since you've done your research. I read that California was a tmj mandated state... However, I have an hmo now and want to go to PPO in January. Is this considered pre-existing in that case? If i understand youre saying..as long as you have insurance and you switch its okay?
Second question..do you know if Principal covers TMJ, thats the insurance I would have.
Second question..do you know if Principal covers TMJ, thats the insurance I would have.
raylp
11-30-2005, 05:24 PM
I just found a copy of my State by state mandate sheet.
It says that Nevada prohibits ins companies from excluding TMJ coverage. However, treatments which are recognized as dental may be excluded. Also insurers may limit TMD benefits to 50% of usual and customary charges and to treatment which is medically necessary.
In california-
Insurers that cover diagnsotic or surgical procedres involving bones or joints are prohibited from discriminating against similar procedures involving the face or jaw, if medically necessary.....
Look up "states with mandatory TMJ coverage" on a major search engine and you will find this.
As far as switching from HMO to PPO, that in my opnion, but check it out before hand, and get it in writing if necessary, would mean that as long as you haven't gone over too long without coverage, 64 days here in NY, you have had continuous coverage. It shouldn't matter if HMO or PPO.
But you need to ask someone at the PPO company to be sure, and get it in writing to be safe.
It says that Nevada prohibits ins companies from excluding TMJ coverage. However, treatments which are recognized as dental may be excluded. Also insurers may limit TMD benefits to 50% of usual and customary charges and to treatment which is medically necessary.
In california-
Insurers that cover diagnsotic or surgical procedres involving bones or joints are prohibited from discriminating against similar procedures involving the face or jaw, if medically necessary.....
Look up "states with mandatory TMJ coverage" on a major search engine and you will find this.
As far as switching from HMO to PPO, that in my opnion, but check it out before hand, and get it in writing if necessary, would mean that as long as you haven't gone over too long without coverage, 64 days here in NY, you have had continuous coverage. It shouldn't matter if HMO or PPO.
But you need to ask someone at the PPO company to be sure, and get it in writing to be safe.
laskalady
12-01-2005, 01:53 AM
ralyp-Thanx for your help! I've already begun looking up whats on the internet regarding this. Thanx again .
Michelle W
12-01-2005, 03:48 AM
laskalady,
When you switch from one plan to another you should be okay. You get what I understand is called a HIPPA Certificate from your former insurance company, which states you have been covered.
If you have a certain doctor, dentist or OS that you are working with I would take the plan you are considering to their insurance person. I would have that insurance person look at the plan you are considering, so they can tell you what it will and will not cover.
I am sorry but I do not remember you particular situation as to what you need done.
In Missouri Principal does not cover anything surgical regarding TMJ nor does it even cover the splint/orthodic.
If you are in state where it is mandated then Principal has to follow the law of the state you live in. I am glad you are in a state that is mandated to treat you.
Good luck,
Michelle
When you switch from one plan to another you should be okay. You get what I understand is called a HIPPA Certificate from your former insurance company, which states you have been covered.
If you have a certain doctor, dentist or OS that you are working with I would take the plan you are considering to their insurance person. I would have that insurance person look at the plan you are considering, so they can tell you what it will and will not cover.
I am sorry but I do not remember you particular situation as to what you need done.
In Missouri Principal does not cover anything surgical regarding TMJ nor does it even cover the splint/orthodic.
If you are in state where it is mandated then Principal has to follow the law of the state you live in. I am glad you are in a state that is mandated to treat you.
Good luck,
Michelle
laskalady
12-02-2005, 08:06 PM
Thanx Michelle W- so Missouri isnt a tmj mandated state? I thought I read that it was. This is horrible that the insurance companies put us through more stress, when were under enough stress as it is. I've been calling around to certain places such as headache, tmj, and sinus centers..and they are either accepting some hmo i dont have or no insurance at all. I guess I have to keep calling. Thanks again for your reply!