Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) A dental benefits plan offered under this
program shall exclude:
(1) Any benefits specified
as excluded within Section
2699.6709 or Section
2699.6711.
(2) Any benefits in excess of limits specified in
Section 2699.6709 or Section
2699.6711.
(3) Services, supplies, items, procedures or
equipment, which are not medically necessary as determined by the plan, unless
otherwise specified in Section
2699.6709 or Section
2699.6711.
(4) Any benefits received or costs that were
incurred in connection with any dental procedures started prior to the subscriber's
effective date of coverage. This exclusion does not apply to covered services to
treat complications arising from services received prior to the subscriber's
effective date of coverage.
(5) Any
benefits that are received subsequent to the time the subscriber's coverage
ends.
(6) Experimental or
investigational services, including any treatment, therapy, procedure, drug or drug
usage, facility or facility usage, equipment or equipment usage, device or device
usage, or supply which is not recognized as being in accordance with generally
accepted professional medical standards, or for which the safety and efficiency have
not been determined for use in the treatment of a particular illness, injury or
medical condition for which the item or service in question is recommended or
prescribed.
(7) Dental services that are
received in an emergency care setting for conditions that are not emergencies if the
subscriber reasonably should have known that an emergency care situation did not
exist.
(8) Procedures, appliances, or
restorations to correct congenital or developmental malformations are not covered
benefits unless specifically listed in Section
2699.6709 or Section
2699.6711.
(9) Cosmetic dental care.
(10) General anesthesia or intravenous/conscious
sedation unless specifically listed as a benefit or is given by a dentist for
covered oral surgery.
(11) Hospital
charges of any kind.
(12) Major surgery
for fractures and dislocations.
(13)
Loss or theft of dentures or bridgework.
(14) Malignancies.
(15) Dispensing of drugs not normally supplied in
a dental office.
(16) Additional
treatment costs incurred because a dental procedure is unable to be performed in the
dentist's office due to the general health and physical limitations of the
subscriber.
(17) The cost of precious
metals used in any form of dental benefits.
(18) The surgical removal of implants.
(19) Services of a pedodontist/pediatric dentist
for subscriber children except when a subscriber child is unable to be treated by
his or her panel provider, or treatment by a pedodontist/pediatric dentist is
medically necessary, or his or her panel provider is a pedodontist/pediatric
dentist.
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. New subsection (d) filed 3-21-2000 as an emergency;
operative 3-21-2000 (Register 2000, No. 12). A Certificate of Compliance must be
transmitted to OAL by 7-19-2000 or emergency language will be repealed by operation
of law on the following day.
4. Certificate of Compliance as to 3-21-2000
order transmitted to OAL 6-23-2000 and filed 7-17-2000 (Register 2000, No.
29).
5. Renumbering of former section 2699.6713 to section
2699.6715 and renumbering of former
section 2699.6711 to section 2699.6713,
including 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.
6. Certificate of Compliance as to 4-29-2002 order,
including repealer of subsection (a)(8) and subsection renumbering, transmitted to
OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).
7. Amendment
filed 9-15-2008; operative 10-15-2008 (Register 2008, No.
38).
Note: Authority cited: Sections
12693.21 and
12693.755,
Insurance Code. Reference: Sections
12693.21,
12693.63 and
12693.755,
Insurance Code.
