Current through Register 2024 Notice Reg. No. 12, March 22, 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.
