Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The basic scope of benefits for subscriber
children offered by a participating dental plan must comply with all requirements of
the Knox-Keene Health Care Service Plan Act of 1975, including amendments as well as
its applicable regulations, and shall include all of the benefits and services
listed in this section, subject to the exclusions listed in Section
2699.6713.
The covered dental benefit is limited to the benefit level for the
least costly dentally appropriate alternative. If a more costly, optional
alternative is chosen by the applicant, the applicant will be responsible for all
charges in excess of the covered dental benefit.
No other dental benefits shall be permitted to be offered by a
participating dental plan as part of the program. The basic scope of dental benefits
shall be as follows:
(1) Diagnostic and
Preventive Benefits
(A) Initial and periodic oral
examinations.
(B) Consultations,
including specialist consultations.
(C)
Roentgenology, limited as follows:
1. Bitewing
x-rays in conjunction with periodic examinations are limited to one series of four
films in any 6 consecutive month period. Isolated bitewing or periapical films are
allowed on an emergency or episodic basis.
2. Full mouth x-rays in conjunction with periodic
examinations are limited to once every 24 consecutive months.
3. Panoramic film x-rays are limited to once every
24 consecutive months.
(D)
Prophylaxis services, limited as follows:
Not to exceed two in a twelve month period.
(E) Topical fluoride treatment.
(F) Dental sealant treatments, limited as follows:
Permanent first and second molars only.
(G) Space maintainers, including removable acrylic
and fixed band type.
(H) Preventive
dental education and oral hygiene instruction.
(2) Restorative Dentistry
(A) Restorations, limited as follows:
1. Amalgam, composite resin, acrylic, synthetic or
plastic restorations for treatment of caries. If the tooth can be restored with such
materials, any other restoration such as a crown or jacket is considered
optional.
2. Composite resin or acrylic
restorations in posterior teeth are optional.
3. Micro filled resin restorations which are
non-cosmetic.
4. Replacement of a
restoration is covered only when it is defective, as evidenced by conditions such as
recurrent caries or fracture, and replacement is dentally
necessary.
(B) Use of pins and
pin build-up in conjunction with a restoration.
(C) Sedative base and sedative
fillings.
(3) Oral Surgery
(A) Extractions, including surgical
extractions
(B) Removal of impacted
teeth, limited as follows: 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
(G) Treatment of mandibular torus
(H) Frenectomy
(I) Incision and drainage of abscesses.
(J) Post-operative services including exams,
suture removal and treatment of complications.
(K) Root recovery (separate
procedure).
(4) Endodontics
(A) Direct pulp capping
(B) Pulpotomy and vital pulpotomy
(C) Apexification filling with calcium
hydroxide
(D) Root amputation
(E) Root canal therapy, including culture canal,
and retreatment of previous root canal therapy limited as follows: Retreatment of
root canals is a covered benefit only if clinical or radiographic signs of abscess
formation are present, and/or the patient is experiencing symptoms. Removal or
retreatment of silver points, overfills, underfills, incomplete fills, or broken
instruments lodged in a canal, in the absence of pathology, is not a covered
benefit.
(F) Apicoectomy
(G) Vitality tests
(5) Periodontics
(A) Emergency treatment, including treatment for
periodontal abscess and acute periodontitis.
(B) Periodontal scaling and root planing, and
subgingival curettage, limited as follows:
Five quadrant treatments in any 12 consecutive
months.
(C)
Gingivectomy
(D) Osseous or
muco-gingival surgery
(6)
Crowns and Fixed Bridges
(A) Crowns, including
those made of acrylic, acrylic with metal, porcelain, porcelain with metal, full
metal, gold onlay or three-quarter crown, and stainless steel. Related dowel pins
and pin build-up are also included. Crowns are limited as follows:
1. Replacement of each unit is limited to once
every 36 consecutive months, except when the crown is no longer functional as
determined by the dental plan.
2. Only
acrylic crowns and stainless steel crowns are a benefit for children under 12 years
of age. If other types of crowns are chosen as an optional benefit for children
under 12 years of age, the covered dental benefit level will be that of an acrylic
crown.
3. Crowns will be covered only if
there is not enough retentive quality left in the tooth to hold a filling. For
example, if the buccal or lingual walls are either fractured or decayed to the
extent that they will not hold a filling.
4. Veneers posterior to the second bicuspid are
considered optional. An allowance will be made for a cast full
crown.
(B) Fixed bridges,
which are cast, porcelain baked with metal, or plastic processed to gold, are
limited as follows:
1. Fixed bridges will be used
only when a partial cannot satisfactorily restore the case. If fixed bridges are
used when a partial could satisfactorily restore the case, it is considered optional
treatment.
2. A fixed bridge is covered
when it is necessary to replace a missing permanent anterior tooth in a person 16
years of age or older and the patient's oral health and general dental condition
permits. Under the age of 16, it is considered optional dental treatment. If
performed on a subscriber under the age of 16, the applicant must pay the difference
in cost between the fixed bridge and a space maintainer.
3. Fixed bridges used to replace missing posterior
teeth are considered optional when the abutment teeth are dentally sound and would
be crowned only for the purpose of supporting a pontic.
4. Fixed bridges are optional when provided in
connection with a partial denture on the same arch.
5. Replacement of an existing fixed bridge is
covered only when it cannot be made satisfactory by repair.
(C) The program allows up to five units of crown
or bridgework per arch. Upon the sixth unit, the treatment is considered full mouth
reconstruction which is optional treatment.
(D) Recementation of crowns, bridges, inlays and
onlays.
(E) Cast post and core,
including cast retention under crowns.
(F) Repair or replacement of crowns, abutments or
pontics.
(7) Removable
Prosthetics
(A) Dentures, full maxillary, full
mandibular, partial upper, partial lower, teeth, clasps and stress breakers, limited
as follows:
1. Partial dentures are not to be
replaced within 36 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. 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.
3. A
removable partial denture is considered an adequate restoration of a case when teeth
are missing on both sides of the dental arch. Other treatments of such cases are
considered optional.
4. Full upper
and/or lower dentures are not to be replaced within 36 consecutive months unless the
existing denture is unsatisfactory and cannot be made satisfactory by reline or
repair.
5. 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 applicant will be responsible for all additional
charges.
(B) Office or
laboratory relines or rebases, limited as follows:
One per arch in any 12 consecutive months.
(C) Denture repair.
(D) Denture adjustment.
(E) Tissue conditioning, limited to two per
denture.
(F) Denture
duplication.
(G) Implants are considered
an optional benefit.
(H) Stayplates,
limited as follows:
Stayplates are a benefit only when used as anterior space
maintainers for children.
(8) Orthodontic Treatment, limited as follows:
If the subscriber child meets the eligibility requirements for
medically necessary orthodontia coverage under the California Children's Services
program, benefits shall be provided and determined by the California Children's
Services program.
(9) Other
Dental Benefits
(A) Local anesthetics.
(B) Oral sedatives when dispensed in a dental
office by a practitioner acting within the scope of their licensure.
(C) Nitrous oxide when dispensed in a dental
office by a practitioner acting within the scope of their licensure.
(D) Emergency treatment, palliative
treatment.
(E) Coordination of benefits
with subscriber's health plan in the event hospitalization or out-patient surgery
setting is medically appropriate for dental services.
(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)
(A)
Participating dental plans shall be responsible for identifying subscribers who have
conditions for which they may be eligible to receive services under the California
Children's Services (CCS) Program, and shall refer these individuals to the local
CCS Program for determination of eligibility.
(B) The plan is excused from responsibility from
providing a covered service to treat the subscriber's CCS condition only to the
extent that the treatment is authorized by the CCS program and provided by a CCS
provider as described in the California Code of Regulations, Title 22, Division 2,
Part 2, Subdivision 7, Section 41412.
(C) If a subscriber is determined by the CCS
Program to be eligible for CCS benefits, participating dental plans shall provide
primary care and services unrelated to the CCS eligible condition and shall ensure
coordination of services between plan providers, CCS providers, and the local CCS
program.
(b)
(1) The scope of dental benefits shall also
include all dental benefits which are covered under the California Children's
Services program (Health and Safety Code Section
123800
et seq.), provided the subscriber meets the medical eligibility requirements of that
program, as determined by that program.
(2) When a subscriber is determined by the
California Children's Services Program (Health and Safety Code Section
123800
et seq.) to be eligible for benefits under that program, a participating dental plan
shall not be responsible for the provision of, or payment for, the particular
services authorized by the California Children's Services Program for the particular
subscriber for the treatment of a California Children's Services Program eligible
medical condition. All other services provided under the participating dental plan
shall be available to the subscriber.
(c) If, pursuant to any Workers' Compensation,
Employer's Liability Law, or other legislation of similar purpose or import, a third
party is responsible for all or part of the cost of dental services to treat any
bodily injury or sickness arising from or sustained in the course of any occupation
or employment for compensation, profit or gain, the participating dental plan shall
provide the services at the time of need, and the subscriber or applicant shall
cooperate to assure that the participating dental plan is reimbursed for such
services.
(d) Coverage provided under
the Healthy Families Program is secondary to all other coverage, except Denti-Cal.
Benefits paid under this Program are determined after benefits have been paid as a
result of a subscriber's enrollment in any other dental care program. If dental
services are eligible for reimbursement by insurance or covered under any other
insurance or dental care service plan, the participating dental plan shall provide
the services at the time of need, and the subscriber or applicant shall cooperate to
assure that the participating dental plan is reimbursed for such services.
1. New section
filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate
of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be
repealed by operation of law on the following day.
2. Certificate of
Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register
98, No. 29).
3. Amendment of section heading, section and NOTE filed
4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to
Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be
transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation
of law on the following day.
4. Certificate of Compliance as to 4-29-2002
order transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No.
50).
5. Amendment of subsections (a) and (a)(3)(B), repealer of
subsection (a)(3)(B)1., amendment of subsections (a)(4)(E), (a)(11) and (b)(2), new
subsections (c) and (d) and amendment of NOTE filed 9-15-2008; operative 10-15-2008
(Register 2008, No. 38).
6. Redesignation and amendment of former
subsection (a)(11) as subsection (a)(11)(A), new subsections (a)(11)(B)-(C) and
amendment of NOTE filed 6-30-2011, deemed an emergency pursuant to Insurance Code
section
12693.22;
operative 6-30-2011 (Register 2011, No. 26). A Certificate of Compliance must be
transmitted to OAL by 12-27-2011 or the emergency action will be repealed by
operation of law on the following day.
7. Certificate of Compliance as to
6-30-2011 order transmitted to OAL 12-20-2011 and filed 2-3-2012 (Register 2012, No.
5).
Note: Authority cited: Sections
12693.21,
12693.22,
12693.62 and
12693.755,
Insurance Code. Reference: Sections
12693.21,
12693.62,
12693.63 and
12693.64,
Insurance Code.
