Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The basic scope of benefits for subscriber
parents 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 certain exclusions as 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 benefits.
The covered dental benefit for each subscriber is limited to
fifteen hundred dollars ($1,500) per benefit year effective July 1, 2009.
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) Diagnosis and
Preventive Benefits
(A) Initial and periodic oral
examinations -- oral examinations are benefits only twice in a benefit
year.
(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 a benefit year.
2. Full mouth
x-rays in conjunction with periodic examinations are limited to once in a three-year
period unless special need is shown.
3.
Panoramic film x-rays are limited to once in a three
year-period.
(D) Prophylaxis
services, not to exceed two in a twelve month period. A third cleaning will be
provided as a benefit for high-risk patients in the following categories:
1. Women who are pregnant
2. Subscribers undergoing cancer
chemotherapy
3. Subscribers with
compromising systemic diseases such as diabetes as determined to be medically
necessary for appropriate dental care by the provider and approved by the
plan.
(E) Space maintainers,
including removable acrylic and fixed band type.
(F) Preventive dental education and oral hygiene
instructions
(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. 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)
Gingevectomy
(D) Osseous or
Muco-Gingival Surgery.
(E) Periodontal
procedures which include cleanings are subject to the limitations described in
Subsection 2699.6711(a)(1)(D).
(6) Crown, Jackets, Cast 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 five years.
2. 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.
3. Veneers posterior
to the second biscupid 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 and the patient's
oral health and general dental condition permits.
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 an 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 five years unless:
a. It is
necessary due to natural tooth loss where the addition or replacement of teeth to
the existing partial is not feasible, there has been such an extensive loss of
remaining teeth, or a change in supporting tissues, 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 five years unless the existing
denture is unsatisfactory and cannot be made satisfactory by reline or repair, the
plan determines that there has been such an extensive loss of remaining teeth, or a
change in supporting tissue that the existing appliance cannot be made
satisfactory.
5. The covered dental
benefit for complete dentures will be limited to the benefit level for a standard
procedure. The plan will pay the applicable percentage of the dentist's fee for a
standard partial or complete denture up to a maximum fee allowance (or established
UCR fee). 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 to 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 (appliances
inserted into bone or soft tissue in the jaw usually to anchor a denture) are
covered.
(H) Stayplates -- provided as a
benefit only when used to replace extracted anterior teeth for adults during a
healing period.
(8) 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 outpatient surgery
setting is medically appropriate for dental services.
(9) 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.
(10)
Participating dental plans shall be responsible for identifying subscribers under
the age of 21 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. 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 under the age of 21 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, including new subsection (a) and redesignation of
former subsections (a)-(t) to new subsections (a)(1)-(20), transmitted to OAL 6-5-98
and filed 7-15-98 (Register 98, No. 29).
3. Renumbering of former section
2699.6711 to section
2699.6713 and new section 2699.6711
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), (a)(2), (a)(3), (a)(4),
(a)(4)(E), (a)(5) and (a)(5)(D), new subsection (a)(5)(E), amendment of subsection
(a)(6), new subsections (c) and (d) and amendment of NOTE filed 9-15-2008; operative
10-15-2008 (Register 2008, No. 38).
6. Amendment of subsection (a) filed
1-15-2009, deemed an emergency pursuant to Chapter 758, Statutes of 2008; operative
1-15-2009 (Register 2009, No. 3). A Certificate of Compliance must be transmitted to
OAL by 7-14-2009 or emergency language will be repealed by operation of law on the
following day.
7. Certificate of Compliance as to 1-15-2009 order
transmitted to OAL 7-13-2009 and filed 8-19-2009 (Register 2009, No.
34).
Note: Authority cited: Sections
12693.21 and
12693.755,
Insurance Code. Reference: Sections
12693.21,
12693.63,
12693.64 and
12693.755,
Insurance Code.
