Cal. Code Regs. tit. 10 § 2699.6211

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 2699.6211 - Enrollee Share of Cost for Dental Health Benefit

(a) Every participating dental health carrier shall require copayments for the dental benefits listed in Subsection 2699.6201(a) of these regulations provided to enrollees subject to the following:

(1) In the case of dental health benefit plans offered by participating carriers which are pre-paid dental organizations:

(A) No copayments are charged for benefits listed under Subsection 2699.6201(a)(1), "Diagnostic and Preventive Benefits", with the following exceptions:

1. Emergency oral exams are subject to a $15 copayment.

2. Palliative treatment is subject to a copayment of $10 per office visit.

3. Specialist consultations are subject to a copayment of $30.

4. Roentgenology is only subject to copayments as follows:

a. Full mouth x-rays--$5 per set.

b. Panoramic films--$5 per set.

5. Dental sealant treatments are subject to a copayment of $5 per tooth.

6. Space maintainers are subject to a $50 copayment.

(B) Copayments for benefits listed under Subsection 2699.6201(a)(2), "Restorative Dentistry", are as follows:

1. Amalgam restorations on primary teeth are subject to a copayment of $14 per tooth including one surface plus $4 per each additional surface.

2. Amalgam restorations on permanent teeth are subject to a copayment of $19 per tooth including one surface plus $4 per each additional surface.

3. Plastic composite, composite resin, or other restorations are subject to a copayment of $22 per tooth including one surface plus $4 per each additional surface. In addition to the copayments, if a precious metal (defined as a metal containing in excess of 50 percent gold or highly noble gold alloy) is used instead of a non-precious metal, charges for the precious metal are the responsibility of the enrollee.

4. Sedative fillings are subject to a copayment of $10.

5. Pin use in conjunction with a restoration is subject to a copayment of $20 per tooth.

(C) Copayments for benefits listed under Subsection 2699.6201(a)(3), "Oral Surgery", are as follows:

1. Extractions (uncomplicated) are subject to a copayment of $15.

2. Extractions solely for orthodontic purposes are subject to a copayment of $20 per tooth.

3. Surgical extractions are subject to a copayment of $30.

4. Removal of impacted teeth is subject to a copayment per tooth as follows:

a. Soft tissue impaction--$35.

b. Partially bony impaction--$50.

c. Completely bony impaction--$75.

5. Biopsy of soft or hard oral tissues is subject to a copayment of $20.

6. Alveolectomies are subject to a copayment of $60 in conjunction with an extraction, and $80 without an extraction.

7. Excision of a cyst or neoplasm in conjunction with an extraction is not subject to a copayment. Excision of cysts and neoplasms as a separate procedure is subject to copayments as follows:

a. Cysts--$25.

b. Neoplasms of no more than 1.25 centimeters--$30.

c. Neoplasms larger than 1.25 centimeters--$60.

8. Removal of palatal torus is subject to a copayment of $50.

9. Removal of mandibular torus is subject to a copayment of $50.

10. Frenulectomy is subject to a copayment of $20.

11. Copayments are not required for incisions and drainage of abscesses.

12. Copayments are not required for post-operative services.

(D) Copayments for benefits listed under Subsection 2699.6201(a)(4), "Endodontics", are as follows:

1. Direct pulp capping is subject to a copayment of $10.

2. Therapeutic pulpotomy is subject to a copayment of $15.

3. Apexification filling with calcium hydroxide is subject to a copayment of $10.

4. Root amputation is subject to a copayment of $60 per root.

5. Root canal therapy is subject to copayments as follows:

a. Bicuspid root canal--$75

b. Molar root canal with one canal--$100.

c. Molar root canal with two canals--$125.

d. Molar root canal with three canals--$150.

e. Molar root canal with four canals--$175.

f. Anterior root canal--$50.

6. An apicoectomy and/or retrograde filling performed in conjunction with root canal therapy is subject to a copayment of $50 per canal. When performed as a separate procedure, an apicoectomy and/or retrograde filling is subject to a copayment of $75 for the first canal and $60 for each additional canal.

7. Vitality tests are not subject to a copayment.

(E) Copayments for benefits listed under Subsection 2699.6201(a)(5), "Periodontics", are as follows:

1. Periodontal scaling performed in the presence of gingival inflammation is subject to a copayment of $15 per quadrant.

2. Periodontal scaling and root planing, gingival flap procedure, and subgingival curettage, are collectively subject to a copayment of $50 per quadrant.

3. Gingivectomy or gingivoplasty is subject to a copayment of the lesser of $100 per quadrant or $35 per tooth.

4. Osseous or muco-gingival surgery is subject to a copayment of the lesser $200 per quadrant or $75 per tooth.

5. Limited occlusal adjustment is subject to a copayment of $20.

(F) Copayments for benefits listed under Subsection 2699.6201(a)(6), "Crown and Fixed Bridges", are as follows:

1. Stainless steel crowns (prefabricated) are subject to a copayment of $25.

2. Laboratory processed composite resin crowns, inlays or onlays are subject to a copayment of $180.

3. Porcelain or ceramic crowns, porcelain fused to metal crowns, full and 3/4 cast metal crowns, and metallic, porcelain, or ceramic inlays or onlays, are subject to a copayment of $200.

4. Prefabricated post and core for crowns or bridges, including canal preparation, build up material, and any pins, is subject to a copayment of $50.

5. Cast or laboratory post and core for crowns or bridges, including canal preparations, build up material, and any pins, is subject to a copayment of $75.

6. Recementation of crowns, inlays or onlays is subject to a copayment of $10.

7. Repair of a crown is subject to a copayment of $25.

8. Bridge pontics and bridge abutments made of metal, porcelain or ceramic, porcelain fused to metal, and full cast metal are subject to a copayment of $200 for each unit.

9. Recementation of bridges is subject to a copayment of $10 per abutment.

10. Repair of abutments or pontics is subject to a copayment of $25 per unit.

11. Repair or replacement of pontic veneer is subject to a copayment of $40.

(G) Copayments for benefits listed under Subsection 2699.6201(a)(7), "Removable Prosthetics", are as follows:

1. Dentures are subject to copayments as follows:

a. Partial upper or lower without clasps--$50.

b. Partial upper or lower with metal lingual or palatal bar, clasps and acrylic saddles, and acrylic base or cast metal framework--$250.

c. Full upper or lower dentures, standard procedure--$230.

d. Full upper or lower dentures, immediate procedure--$250.

2. Reline or rebase for an upper, lower or partial denture is subject to a copayment per unit as follows:

a. Office--$30.

b. Laboratory--$60.

3. Repair of, or addition to, complete upper or lower, or partial dentures is subject to a copayment per unit as follows:

a. Repair of broken unit--$25

b. Replacement of a tooth or addition of a tooth--$25.

4. Tissue conditioning for complete upper or lower, or for partial dentures is subject to a copayment per unit of $25.

5. Copayments are not required for denture adjustments.

(H) Copayments for benefits listed under Subsection 2699.6201(a)(8), "Orthodontia", are as follows:

1. Treatment for the initial 24 months of an orthodontic treatment program is subject to a $350 start-up fee per patient, and is also subject to a copayment of $1,150 for enrollees up to age 18, and a copayment of $1,500 for enrollees 18 years of age and older.

2. Treatment beyond the initial 24 months is subject to an additional copayment of $50 per month, until active treatment is concluded.

3. The retention phase of an orthodontic treatment program shall be subject to a copayment of up to $350.

4. Alternative, partial or interceptive orthodontic treatment is subject to a copayment of 50% of usual, customary or reasonable charges.

(I) There are no copayments for benefits listed under Subsection 2699.6201(a)(9), "Other Dental Benefits."

(J) Other charges shall apply as follows:

1. Failure to cancel an appointment 24 hours in advance of the appointment may incur a charge of up to $20.

(K) Enrollees are responsible for 100% of any additional charges for services provided in excess of the benefit level.

(2) In the case of dental benefit plans offered by participating dental carriers which are fee-for-service dental organizations:

(A) Exclusive of orthodontia, the sum of the benefits provided in a benefit year shall not exceed $1,000 for a person enrolled in the dental benefits plan.

(B) The sum of lifetime benefits provided for orthodontia shall not exceed $1,500 for a person enrolled in the dental benefits plan.

(C) An annual benefit year deductible per enrollee shall apply. The deductible per enrollee shall be $50, with a family maximum of $150. No deductible shall apply for services for which no copayment is required.

(D) Copayments are listed as a percentage of the covered benefit, which is limited to usual, customary or reasonable charges.

(E) No copayments are charged for benefits listed under Subsection 2699.6201(a)(1), "Diagnostic and Preventive Benefits", with the following exceptions:

1. Emergency oral examinations are subject to a 20% copayment per occurrence.

2. Palliative treatments are subject to a copayment of 20%.

3. Specialist consultations are subject to a copayment of 20%.

4. Roentgenology is only subject to copayments for full mouth x-rays and panoramic films, which are each subject to a copayment of 20%.

5. Dental sealant treatments are subject to a copayment of 20% per tooth.

6. Space maintainers are subject to a 50% copayment.

(F) Copayments for benefits listed under Subsection 2699.6201(a)(2), "Restorative Dentistry", are 20%. In addition to the copayments, if a precious metal (defined as a metal containing in excess of 50 percent gold or highly noble gold alloy) is used instead of a non-precious metal, charges for the precious metal are the responsibility of the enrollee.

(G) Copayments for benefits listed under Subsection 2699.6201(a)(3), "Oral Surgery", are 20%, with the following exceptions:

1. Extractions solely for orthodontic purposes are subject to a copayment of 50%.

2. Excisions of cysts or neoplasms in conjunction with an extraction are not subject to a copayment.

3. Incisions and drainage of abscesses are not subject to a copayment.

4. Post-operative services are not subject to a copayment.

(H) Copayments for benefits listed under Subsection 2699.6201(a)(4), "Endodontics", are 20%, with the following exceptions:

1. Root amputations are subject to a copayment of 50%.

2. Apicoectomy and/or retrograde fillings are subject to a copayment of 50%.

3. Vitality tests are not subject to a copayment.

(I) Copayments for benefits listed under Subsection 2699.6201(a)(5), "Periodontics", shall be 20%, with the following exceptions:

1. Gingivectomy or gingivoplasty is subject to a copayment of 50%.

2. Osseous or muco-gingival surgery is subject to a copayment of 50%.

(J) Copayments for benefits listed under Subsection 2699.6201(a)(6), "Crowns and Fixed Bridges", shall be 50%.

(K) Copayments for benefits listed under Subsection 2699.6201(a)(7), "Removable Prosthetics", shall be 50% with the following exception:

1. Copayments are not required for denture adjustments.

(L) Copayments for benefits listed under Subsection 2699.6201(a)(8), "Orthodontia", shall be subject to a copayment of 50%.

(M) There are no copayments for benefits listed under Subsection 2699.6201(a)(9), "Other Dental Benefits."

(N) Other charges shall apply as follows:

1. Failure to cancel an appointment 24 hours in advance of the appointment may incur a charge of up to $20.

(O) Enrollees are responsible for 100% of any additional charges for services provided in excess of the benefit level.

Cal. Code Regs. Tit. 10, § 2699.6211

1. New section filed 5-23-94 as an emergency; operative 5-23-94 (Register 94, No. 21). A Certificate of Compliance must be transmitted to OAL by 9-20-94 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 5-23-94 order transmitted with amendment of subsection (a)(2)(G)4 to OAL 9-16-94 and filed 10-27-94 (Register 94, No. 43).
3. Editorial correction of subsection (a)(1)(F)11 (Register 94, No. 43).
4. Amendment of subsection (a)(1)(A) filed 10-18-95; operative 10-18-95 pursuant to Government Code section 11343.4(d) (Register 95, No. 42).

Note: Authority cited: Section 10731, Insurance Code. Reference: Section 10731, Insurance Code.