California Code of Regulations
Title 10 - Investment
Chapter 5.7 - Voluntary Alliance Uniting Employers Purchasing Pool (the Health Insurance Plan of California)
Article 3 - Benefits
Section 2699.6211 - Enrollee Share of Cost for Dental Health Benefit
Universal Citation: 10 CA Code of Regs 2699.6211
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Every participating dental health carrier shall require copayments for the dental benefits listed in Subsection 2699.6201(a) of these regulations provided to enrollees subject to the following:
(1) In the case of dental health benefit plans
offered by participating carriers which are pre-paid dental organizations:
(A) No copayments are charged for benefits listed
under Subsection
2699.6201(a)(1),
"Diagnostic and Preventive Benefits", with the following exceptions:
1. Emergency oral exams are subject to a $15
copayment.
2. Palliative treatment is
subject to a copayment of $10 per office visit.
3. Specialist consultations are subject to a
copayment of $30.
4. Roentgenology is
only subject to copayments as follows:
a. Full
mouth x-rays--$5 per set.
b. Panoramic
films--$5 per set.
5. Dental
sealant treatments are subject to a copayment of $5 per tooth.
6. Space maintainers are subject to a $50
copayment.
(B) Copayments for
benefits listed under Subsection
2699.6201(a)(2),
"Restorative Dentistry", are as follows:
1.
Amalgam restorations on primary teeth are subject to a copayment of $14 per tooth
including one surface plus $4 per each additional surface.
2. Amalgam restorations on permanent teeth are
subject to a copayment of $19 per tooth including one surface plus $4 per each
additional surface.
3. Plastic
composite, composite resin, or other restorations are subject to a copayment of $22
per tooth including one surface plus $4 per each additional surface. In addition to
the copayments, if a precious metal (defined as a metal containing in excess of 50
percent gold or highly noble gold alloy) is used instead of a non-precious metal,
charges for the precious metal are the responsibility of the enrollee.
4. Sedative fillings are subject to a copayment of
$10.
5. Pin use in conjunction with a
restoration is subject to a copayment of $20 per tooth.
(C) Copayments for benefits listed under
Subsection 2699.6201(a)(3), "Oral
Surgery", are as follows:
1. Extractions
(uncomplicated) are subject to a copayment of $15.
2. Extractions solely for orthodontic purposes are
subject to a copayment of $20 per tooth.
3. Surgical extractions are subject to a copayment
of $30.
4. Removal of impacted teeth is
subject to a copayment per tooth as follows:
a.
Soft tissue impaction--$35.
b. Partially
bony impaction--$50.
c. Completely bony
impaction--$75.
5. Biopsy of
soft or hard oral tissues is subject to a copayment of $20.
6. Alveolectomies are subject to a copayment of
$60 in conjunction with an extraction, and $80 without an extraction.
7. Excision of a cyst or neoplasm in conjunction
with an extraction is not subject to a copayment. Excision of cysts and neoplasms as
a separate procedure is subject to copayments as follows:
a. Cysts--$25.
b. Neoplasms of no more than 1.25
centimeters--$30.
c. Neoplasms larger
than 1.25 centimeters--$60.
8.
Removal of palatal torus is subject to a copayment of $50.
9. Removal of mandibular torus is subject to a
copayment of $50.
10. Frenulectomy is
subject to a copayment of $20.
11.
Copayments are not required for incisions and drainage of abscesses.
12. Copayments are not required for post-operative
services.
(D) Copayments for
benefits listed under Subsection
2699.6201(a)(4),
"Endodontics", are as follows:
1. Direct pulp
capping is subject to a copayment of $10.
2. Therapeutic pulpotomy is subject to a copayment
of $15.
3. Apexification filling with
calcium hydroxide is subject to a copayment of $10.
4. Root amputation is subject to a copayment of
$60 per root.
5. Root canal therapy is
subject to copayments as follows:
a. Bicuspid root
canal--$75
b. Molar root canal with one
canal--$100.
c. Molar root canal with
two canals--$125.
d. Molar root canal
with three canals--$150.
e. Molar root
canal with four canals--$175.
f.
Anterior root canal--$50.
6.
An apicoectomy and/or retrograde filling performed in conjunction with root canal
therapy is subject to a copayment of $50 per canal. When performed as a separate
procedure, an apicoectomy and/or retrograde filling is subject to a copayment of $75
for the first canal and $60 for each additional canal.
7. Vitality tests are not subject to a
copayment.
(E) Copayments for
benefits listed under Subsection
2699.6201(a)(5),
"Periodontics", are as follows:
1. Periodontal
scaling performed in the presence of gingival inflammation is subject to a copayment
of $15 per quadrant.
2. Periodontal
scaling and root planing, gingival flap procedure, and subgingival curettage, are
collectively subject to a copayment of $50 per quadrant.
3. Gingivectomy or gingivoplasty is subject to a
copayment of the lesser of $100 per quadrant or $35 per tooth.
4. Osseous or muco-gingival surgery is subject to
a copayment of the lesser $200 per quadrant or $75 per tooth.
5. Limited occlusal adjustment is subject to a
copayment of $20.
(F)
Copayments for benefits listed under Subsection
2699.6201(a)(6),
"Crown and Fixed Bridges", are as follows:
1.
Stainless steel crowns (prefabricated) are subject to a copayment of $25.
2. Laboratory processed composite resin crowns,
inlays or onlays are subject to a copayment of $180.
3. Porcelain or ceramic crowns, porcelain fused to
metal crowns, full and 3/4 cast metal crowns, and metallic, porcelain, or ceramic
inlays or onlays, are subject to a copayment of $200.
4. Prefabricated post and core for crowns or
bridges, including canal preparation, build up material, and any pins, is subject to
a copayment of $50.
5. Cast or
laboratory post and core for crowns or bridges, including canal preparations, build
up material, and any pins, is subject to a copayment of $75.
6. Recementation of crowns, inlays or onlays is
subject to a copayment of $10.
7. Repair
of a crown is subject to a copayment of $25.
8. Bridge pontics and bridge abutments made of
metal, porcelain or ceramic, porcelain fused to metal, and full cast metal are
subject to a copayment of $200 for each unit.
9. Recementation of bridges is subject to a
copayment of $10 per abutment.
10.
Repair of abutments or pontics is subject to a copayment of $25 per unit.
11. Repair or replacement of pontic veneer is
subject to a copayment of $40.
(G) Copayments for benefits listed under
Subsection 2699.6201(a)(7),
"Removable Prosthetics", are as follows:
1.
Dentures are subject to copayments as follows:
a.
Partial upper or lower without clasps--$50.
b. Partial upper or lower with metal lingual or
palatal bar, clasps and acrylic saddles, and acrylic base or cast metal
framework--$250.
c. Full upper or lower
dentures, standard procedure--$230.
d.
Full upper or lower dentures, immediate procedure--$250.
2. Reline or rebase for an upper, lower or partial
denture is subject to a copayment per unit as follows:
a. Office--$30.
b. Laboratory--$60.
3. Repair of, or addition to, complete upper or
lower, or partial dentures is subject to a copayment per unit as follows:
a. Repair of broken unit--$25
b. Replacement of a tooth or addition of a
tooth--$25.
4. Tissue
conditioning for complete upper or lower, or for partial dentures is subject to a
copayment per unit of $25.
5. Copayments
are not required for denture adjustments.
(H) Copayments for benefits listed under
Subsection 2699.6201(a)(8),
"Orthodontia", are as follows:
1. Treatment for
the initial 24 months of an orthodontic treatment program is subject to a $350
start-up fee per patient, and is also subject to a copayment of $1,150 for enrollees
up to age 18, and a copayment of $1,500 for enrollees 18 years of age and
older.
2. Treatment beyond the initial
24 months is subject to an additional copayment of $50 per month, until active
treatment is concluded.
3. The retention
phase of an orthodontic treatment program shall be subject to a copayment of up to
$350.
4. Alternative, partial or
interceptive orthodontic treatment is subject to a copayment of 50% of usual,
customary or reasonable charges.
(I) There are no copayments for benefits listed
under Subsection
2699.6201(a)(9),
"Other Dental Benefits."
(J) Other
charges shall apply as follows:
1. Failure to
cancel an appointment 24 hours in advance of the appointment may incur a charge of
up to $20.
(K) Enrollees are
responsible for 100% of any additional charges for services provided in excess of
the benefit level.
(2) In the
case of dental benefit plans offered by participating dental carriers which are
fee-for-service dental organizations:
(A) Exclusive
of orthodontia, the sum of the benefits provided in a benefit year shall not exceed
$1,000 for a person enrolled in the dental benefits plan.
(B) The sum of lifetime benefits provided for
orthodontia shall not exceed $1,500 for a person enrolled in the dental benefits
plan.
(C) An annual benefit year
deductible per enrollee shall apply. The deductible per enrollee shall be $50, with
a family maximum of $150. No deductible shall apply for services for which no
copayment is required.
(D) Copayments
are listed as a percentage of the covered benefit, which is limited to usual,
customary or reasonable charges.
(E) No
copayments are charged for benefits listed under Subsection
2699.6201(a)(1),
"Diagnostic and Preventive Benefits", with the following exceptions:
1. Emergency oral examinations are subject to a
20% copayment per occurrence.
2.
Palliative treatments are subject to a copayment of 20%.
3. Specialist consultations are subject to a
copayment of 20%.
4. Roentgenology is
only subject to copayments for full mouth x-rays and panoramic films, which are each
subject to a copayment of 20%.
5. Dental
sealant treatments are subject to a copayment of 20% per tooth.
6. Space maintainers are subject to a 50%
copayment.
(F) Copayments for
benefits listed under Subsection
2699.6201(a)(2),
"Restorative Dentistry", are 20%. In addition to the copayments, if a precious metal
(defined as a metal containing in excess of 50 percent gold or highly noble gold
alloy) is used instead of a non-precious metal, charges for the precious metal are
the responsibility of the enrollee.
(G)
Copayments for benefits listed under Subsection
2699.6201(a)(3), "Oral
Surgery", are 20%, with the following exceptions:
1. Extractions solely for orthodontic purposes are
subject to a copayment of 50%.
2.
Excisions of cysts or neoplasms in conjunction with an extraction are not subject to
a copayment.
3. Incisions and drainage
of abscesses are not subject to a copayment.
4. Post-operative services are not subject to a
copayment.
(H) Copayments for
benefits listed under Subsection
2699.6201(a)(4),
"Endodontics", are 20%, with the following exceptions:
1. Root amputations are subject to a copayment of
50%.
2. Apicoectomy and/or retrograde
fillings are subject to a copayment of 50%.
3. Vitality tests are not subject to a
copayment.
(I) Copayments for
benefits listed under Subsection
2699.6201(a)(5),
"Periodontics", shall be 20%, with the following exceptions:
1. Gingivectomy or gingivoplasty is subject to a
copayment of 50%.
2. Osseous or
muco-gingival surgery is subject to a copayment of 50%.
(J) Copayments for benefits listed under
Subsection 2699.6201(a)(6),
"Crowns and Fixed Bridges", shall be 50%.
(K) Copayments for benefits listed under
Subsection 2699.6201(a)(7),
"Removable Prosthetics", shall be 50% with the following exception:
1. Copayments are not required for denture
adjustments.
(L) Copayments
for benefits listed under Subsection
2699.6201(a)(8),
"Orthodontia", shall be subject to a copayment of 50%.
(M) There are no copayments for benefits listed
under Subsection
2699.6201(a)(9),
"Other Dental Benefits."
(N) Other
charges shall apply as follows:
1. Failure to
cancel an appointment 24 hours in advance of the appointment may incur a charge of
up to $20.
(O) Enrollees are
responsible for 100% of any additional charges for services provided in excess of
the benefit level.
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 with amendment of
subsection (a)(2)(G)4 to OAL 9-16-94 and filed 10-27-94 (Register 94, No.
43).
3. Editorial correction of subsection (a)(1)(F)11 (Register 94, No.
43).
4. Amendment of subsection (a)(1)(A) filed 10-18-95; operative
10-18-95 pursuant to Government Code section
11343.4(d)
(Register 95, No. 42).
Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.
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