Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Every participating dental plan shall require
copayments for the dental benefits provided to subscriber parents subject to the
following:
(1) No copayments shall be charged for
benefits listed under Subsection
2699.6711(a)(1),
"Diagnostic and Preventive."
(2) No
copayments shall be charged for benefits listed under Subsection
2699.6711(a)(2),
"Restorative Dentistry", with the following exceptions:
(A) Micro filled resin restorations (non-cosmetic,
acid etched, bonded, light cured):
1. $40 per
surface
2. $65 for two or more
surfaces
(3) No
copayments shall be charged for benefits listed under subsection
2699.6711(a)(3), "Oral
Surgery", with the following exceptions:
(A)
Removal of impacted teeth is subject to a copayment per tooth as follows:
1. Partially bony impaction -- $15
copayment.
2. Complete bony impaction --
$15 copayment.
(B) Root
recovery as a separate procedure -- $5 per root.
(4) No copayments shall be charged for benefits
listed under Subsection
2699.6711(a)(4),
"Endodontics" with the following exceptions:
(A)
Root canal therapy or retreatment of previous root canal therapy (excluding
restoration) is subject to copayments as follows:
1. 1 canal -- $20
2. 2 canals -- $40
3. 3 canals -- $60
4. 4 canals -- $80
(B) An apicoectomy performed in conjunction with
filling or root canal therapy at the same time is subject to a copayment of $60 per
canal. When performed as a separate procedure, an apicoectomy is subject to a
copayment of $50 per canal.
(5) No copayments shall be charged for benefits
listed under subsection
2699.6711(a)(5),
"Periodontics", with the following exceptions:
(A)
Osseous or muco-gingival surgery is subject to a copayment of $150 per quadrant
(includes post surgical visits).
(B)
Gingivectomy is subject to a $5 copayment per tooth (fewer than six
teeth).
(6) No copayments
shall be charged for benefits listed under subsection
2699.6711(a)(6),
"Crowns and Bridges" (per unit), with the following exceptions:
(A) Porcelain crowns; porcelain fused to metal
crowns (excluding molars) full crowns, or 3/4 crowns; are each subject to a
copayment of $50. Cast post and core are subject to $40 per unit copayment, and
bonded Maryland Bridge is subject to $50 copayment per unit.
(B) Pontics are each subject to a copayment of
$50.
(7) "Removable
Prosthetics" as listed under Subsection
2699.6711(a)(7) are
subject to the following copayments:
(A) Dentures
are subject to copayments as follows:
1. Complete
upper denture (3 adjustments within 60 days) -- $65.
2. Complete lower denture (3 adjustments within 60
days) -- $65.
3. Partial acrylic upper
or lower denture with clasps -- $5.
4.
Partial acrylic upper or lower denture with 2 chrome cobalt allow clasps is subject
to a base fee of $65.
5. Partial lower
or upper denture with chrome cobalt allow, lingual or palatal bar, clasps and
acrylic saddles -- $65 base fee (included two clasps).
6. Removable unilateral partial denture --
$50.
7. Stayplate (maximum two teeth
included) -- $60.
(B) Reline
for an upper, lower or partial denture is subject to a copayment per unit as
follows:
1. Office reline -- No
copayment.
2. Laboratory reline -- $15
copayment.
(C) Denture
duplication -- $20 copayment.
(D)
Denture Repairs
1. Adding teeth to partial denture
to replace natural tooth:
First tooth -- $10 copayment.
Each additional tooth -- $5 copayment.
2. Broken partial denture (no teeth involved)
Replacement broken clasp -- $5 copayment.
3. Add clasp with rest -- $5
copayment.
(8) Other
Services After hour visit -- $35 copayment.
Broken appointment -- $5 copayment.
(9) Implants -- If implants are utilized, the plan
will apply the cost of a standard full or partial denture towards the cost of
implants and appliances constructed thereon, and if performed, subscriber parent
must pay the difference plus any applicable copayment. Surgical removal of implants
is not covered.
(b) No
deductibles shall be charged to subscriber parents for dental benefits.
(c) No copayments or fees shall apply if the
applicant has submitted acceptable documentation as described in Subsection
2699.6600(c)(1)(GG)
that the applicant or subscriber is American Indian or Alaska Native.
(d) Note: Any procedure not listed in the EOC is
available on a fee-for-service basis.
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. Renumbering of former section 2699.6717 to section
2699.6721 and new section 2699.6717
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 subsection (c) filed 7-31-2003 as an emergency;
operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be
transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation
of law on the following day.
6. Certificate of Compliance as to 7-31-2003
order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No.
1).
7. Amendment of subsection (c) filed 7-1-2004 as an emergency;
operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80, A.B. 1762
(Chapter 230, Stats. 2003) a Certificate of Compliance must be transmitted to OAL by
12-28-2004 or emergency language will be repealed by operation of law on the
following day.
8. Certificate of Compliance as to 7-1-2004 order
transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No.
1).
9. Amendment of subsection (a)(4)(A) 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.
