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