If you are living with TMJ disorder and trying to find the proper care, you probably have an idea of how frustrating the journey to health and healing can be. It can take up a lot of time and energy discovering how to get your TMJ treatments covered by insurance. Going through the hoops of insurance can be a stressful process when you’re just looking for a little relief without draining your bank accounts.
Why Is It So Hard To Get Insurance Coverage For TMJ?
Because of the location of the temporomandibular joints, arguments have been made by both the dental and medical communities over who should claim jurisdiction of the area.
Is jaw joint health the responsibility of a dentist? It’s located near the mouth and its functions impact bite, teeth, and oral health.
Or should it be governed by medical doctors? They have training in bone and joint health and understand the jaw joint as one part of a bigger system.
Learning how to get TMJ covered by insurance is made complicated by the fact that there’s not one particular type of dentist or doctor trained to treat the disorder. Plus, it’s often hard to tell if TMJ dysfunction is a symptom of a dental problem or a health problem. If you had a heart problem, you’d see a cardiologist. When you have jaw pain, you might see a dentist, orthodontist, MD or internist, chiropractor, orthopedic surgeon… the list goes on.
Without a particular path for treatment, insurance companies are less likely to offer solid coverage. In addition to that, many dentists, orthodontists, and chiropractors who treat TMJ don’t operate “in-network”. So it’s up to their patients to submit claims (often after paying in full and upfront) and hope and pray their insurance carrier reimburses them for some of the cost.
In the past, TMJ disorder was a relatively unknown and less-studied condition. It was rare for insurance to offer any kind of coverage without going through a lot of red tape. Luckily, major insurance companies have shifted in recent years as they recognize TMJ as a proper (and common) disorder. (About 12% of the population suffers from TMJ disorder to varying degrees.)
How To Get TMJ Covered By Insurance
First, it’s relatively rare for dental insurance to cover treatment for TMJ disorder. Typically, major medical insurance carriers will provide TMJ coverage if the state mandates it. It is not uncommon, though, for folks who are fully insured to struggle to find care that insurance will support.
You’ll have to check the guidebook of your insurance plan or call their support line to get a detailed understanding of your coverage. Each plan will have specific details of treatment coverage. One carrier may cover a range of TMJ treatments like dental devices (splints or mouth guards), physical therapy, chiropractic and jaw surgery. Others may not cover anything.
Insurance carriers who do cover TMJ disorder will often look for a few things before they authorize coverage upfront or reimburse a claim.
1. Diagnosis
Often, an insurance company will require a diagnosis of any health condition before they cover treatment. Most primary care doctors can diagnose TMJ, but not many have the proper training or tools to treat the condition. You’ll want to get your diagnosis from either a doctor or dentist who can refer you to proper care or from a specialist who will treat your jaw pain.
2. Seriousness Of Condition
Insurance companies don’t like to frivolously spend their money. They’ll often look to the doctors to indicate treatment needed based on the severity of the condition. If your TMJ disorder has a relatively low impact on your life, insurance may not find treatment necessary.
3. Necessity Of Treatment
The seriousness of your condition will determine the necessity of treatment. Health insurance companies only like to cover what doctors consider “medically necessary”. In other words, there has to be little doubt in their minds that you need treatment. If you have a great plan, they may consider preventative treatment, but they will determine that on a case-by-case basis.
Once you have a diagnosis that demonstrates you need treatment, a rep can let you know how your plan covers care. They may pay contribute in full or partially upfront (if your provider bills insurance) or reimburse your expenses. Often, you’ll have either an in-network or out-of-network deductible you need to meet before unlocking coverage benefits.
If your insurance plan says they will reimburse you for a specific treatment, get that in writing. Verify whether or not they need to approve or authorize treatment before you pay for it. You don’t want any surprises or miscommunication to prevent you from getting the reimbursement you’re expecting.
Alternatives To Health Insurance For TMJ
If your carrier doesn’t offer you the coverage you need, there are a few alternatives to lessen the financial impact of TMJ treatment.
Health savings accounts (HSAs) and flexible spending accounts (FSAs) help individuals and families save money for out-of-pocket health-related expenses. An HSA is available to people on high-deductible insurance plans. You may get one either through your employer or open one on your own through a separate agency. An employer must open and offer an FSA on your behalf. Each plan allows you to save money, pre-tax, year-round to cover medical and health expenses when they come up. Because you’re not paying taxes on this money, you’ll be able to sock more of it away, sooner.
If you have a chronic condition like TMJ pain that will call for care throughout the year, these savings plans can help you save money long-term. An HSA often allows saved funds to roll over year after year, while an FSA may have stricter limits on spending funds within the calendar year.
It may take some investigating to determine how to get TMJ covered by insurance. But it’s worth looking into. TMJ treatments are costly, and a treatment that works wonders for one person may not be as effective on another. The road to wellness will be ongoing, so take advantage of whatever financial assistance you may have available to you.
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Disclaimer: This content is meant to be informational and educational only and is not medical advice. This content does not substitute consulting with a medical or dental professional. Living With TMJ makes no claims to diagnose illness or injury. If you have a medical concern, you should consult with your healthcare provider or seek treatment immediately. Never disregard professional medical advice or delay seeking treatment because of something you read in this blog, on this website, or in linked resources.