Current through Register 2024 Notice Reg. No. 12, March 22, 2024
(a) The basic scope of benefits offered by a
participating dental carrier as a dental benefit plan shall include all of the
benefits and services listed in this section, subject to the exclusions listed
in Section
2699.6205. No other dental
benefits shall be permitted to be offered by a participating dental carrier.
The basic scope of dental benefits shall be as follows:
(1) Diagnostic and Preventive Benefits
(A) Initial, periodic and emergency oral
examinations, limited as follows:
1. Routine
oral examinations: one every six months per enrollee.
(B) Palliative treatment.
(C) Consultations, including specialist
consultations.
(D) Roentgenology,
limited as follows:
1. Bitewing x-rays in
conjunction with period examinations are limited to one series of four films in
any 12 consecutive month period.
2.
Full mouth x-rays in conjunction with period examinations are limited to once
every 60 consecutive months.
3.
Panoramic film x-rays are limited to once every 60 consecutive
months.
4. Isolated bitewing or
periapical films are allowed on an emergency or episodic
basis.
(E) Prophylaxis
services, limited as follows:
1. Not to exceed
once in a six month period.
(F) Fluoride treatment, limited as follows:
1. Only for dental benefit plan enrollees
under the age of 18.
2. One every
12 months.
(G) Dental
sealant treatments, limited as follows:
1.
Only for dental plan enrollees under the age of 14.
2. Permanent first and second molars
only.
3. One treatment per tooth in
a 36 consecutive month period.
(H) Space maintainers, limited as follows:
1. Only for dental plan enrollees under the
age of 14.
(I) Preventive
dental education and oral hygiene instruction
(J) Study models
(2) Restorative Dentistry
(A) Restorations, limited as follows:
1. The covered dental benefit is limited to
the benefit level for the least costly dentally appropriate alternative. If a
more costly alternative is chosen by the patient, the patient will be
responsible for all additional charges.
2. Replacement of a restoration is covered
only when it is defective, as evidenced by conditions such as recurrent caries
or fracture, and replacement is necessary for the enrollee's dental
health.
(B) Use of pins
in conjunction with a restoration.
(3) Oral Surgery
(A) Extractions, including surgical
extractions
(B) Removal of impacted
teeth, limited as follows:
1. Surgical removal
of impacted teeth is a covered benefit only when evidence of pathology
exists.
(C) Biopsy of
oral tissues
(D)
Alveolectomies
(E) Excision of
cysts and neoplasms
(F) Treatment
of palatal torus if interfering with a prosthesis
(G) Treatment of mandibular torus if
interfering with a prosthesis
(H)
Frenulectomy
(I) Incision and
drainage of abscesses
(J)
Post-operative services including exams, suture removal and treatment of
complications.
(4)
Endodontics
(A) Direct pulp capping
(B) Therapeutic pulpotomy
(C) Apexification filling with calcium
hydroxide
(E) Root amputation and
Hemisection
(F) Root canal
therapy
(G) Apicoectomy
(H) Retrograde filling
(I) Vitality tests
(5) Periodontics
(A) Periodontal scaling performed in the
presence of gingival inflammation
(B) Periodontal scaling and root planing,
gingival flap procedure, and subgingival curettage, limited as follows:
1. Four quadrant treatments in any 12
consecutive months.
(C)
Gingivectomy or gingivoplasty
(D)
Osseous or muco-gingival surgery
(E) Correction of occlusion, limited to
occlusal adjustment.
(6)
Crowns and Fixed Bridges
(A) Crowns, limited
as follows:
1. Replacement of each unit is
limited to once every 60 consecutive months, with the exception of
prefabricated stainless steel crowns.
(B) Fixed bridges, limited as follows:
1. Fixed bridges are a covered benefit when
there are one or two missing teeth in any one quadrant.
2. Other than in one (1) above, fixed bridges
will be covered only when a partial denture cannot satisfactorily restore the
case. If a fixed bridge is used when a partial could satisfactorily restore the
case, coverage will be provided at the level it would have been for a partial
denture.
3. Replacement of an
existing fixed bridge is covered only when it cannot be made satisfactory by
repair.
4. Replacement of bridge
pontic and bridge abutment units is limited to once every 60 consecutive
months.
(C) Recementation
of crowns or bridges
(D) Inlays and
onlays, limited as follows:
1. Replacement of
each unit is limited to once every 60 consecutive months.
(E) Prefabricated, cast or laboratory posts
and cores for crowns or bridges
(F)
Repair or replacement of crowns, abutments or pontics.
(7) Removable Prosthetics
(A) Dentures, full or partials, teeth, and
clasps, limited as follows:
1. Partial
dentures are not to be replaced within 60 consecutive months, unless:
a. it is necessary due to natural tooth loss
where the addition or replacement of teeth to the existing partial is not
feasible, or
b. the denture is
unsatisfactory and cannot be made satisfactory.
2. Full upper and/or lower dentures are not
to be replaced within 60 consecutive months unless the existing denture is
unsatisfactory and cannot be made satisfactory.
3. The covered dental benefit for complete
dentures will be limited to the benefit level for a standard procedure. If a
more personalized or specialized treatment is chosen by the patient and the
dentist, the patient will be responsible for all additional charges.
4. The covered dental benefit for partial
dentures will be limited to the charges for a cast chrome or acrylic denture if
this would satisfactorily restore an arch. If a more elaborate or precision
appliance is chosen by the patient and the dentist, and is not necessary to
satisfactorily restore an arch, the patient will be responsible for all
additional charges.
(B)
Office or laboratory relines or rebases, limited as follows:
1. One per arch in any 24 consecutive months
for a standard procedure.
2. One
per arch may be performed during the 6 consecutive months after an immediate
procedure. After this initial period, this benefit is limited to one per arch
in any 24 consecutive months.
(C) Denture repair
(D) Denture adjustment
(E) Tissue conditioning
(8) Orthodontia
(A) The basic benefit shall cover a treatment
program and shall include:
1. Start-up
records, examination, consultation, x-rays, study models,
photographs.
2. Final exam, x-rays,
study models, photographs.
3.
Post-treatment retention
(B) Interceptive orthodontic treatment shall
be a benefit if, in the opinion of the dental professional and the dental
carrier, alternative interceptive orthodontic treatment would be a more
appropriate course of treatment for an enrollee under the age of 18 than the
customary orthodontic program described in (A) above.
(9) Other Dental Benefits
(A) Local anesthetics.
(B) Injection of antibiotic
drugs.
(10) This part
shall not be construed to prohibit a dental plan's ability to impose
cost-control mechanisms. Such mechanisms may include but are not limited to
requiring prior authorization for benefits or providing alternative treatments
or services.
(11) The level of
benefits covered under a fee-for-service dental benefit plan shall be limited
to usual, customary or reasonable (UCR) charges.
1. New section
filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A
Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency
language will be repealed by operation of law on the following
day.
2. Certificate of Compliance as to 5-23-94 order transmitted to
OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
3. Editorial
correction of subsection (a)(7)(A)4 (Register 94, No.
43).
Note: Authority cited: Section
10731,
Insurance Code. Reference: Section
10731,
Insurance Code.