Section 2699.6709 - Scope of Dental Benefits for Subscriber Children(a) The basic scope of benefits for subscriber children 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 the exclusions 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 benefit.
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) Diagnostic and Preventive Benefits(A) Initial and periodic oral examinations.(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 any 6 consecutive month period. Isolated bitewing or periapical films are allowed on an emergency or episodic basis.2. Full mouth x-rays in conjunction with periodic examinations are limited to once every 24 consecutive months.3. Panoramic film x-rays are limited to once every 24 consecutive months.(D) Prophylaxis services, limited as follows: Not to exceed two in a twelve month period.
(E) Topical fluoride treatment.(F) Dental sealant treatments, limited as follows: Permanent first and second molars only.
(G) Space maintainers, including removable acrylic and fixed band type.(H) Preventive dental education and oral hygiene instruction.(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, limited as follows: Surgical removal of impacted teeth is a covered benefit only when evidence of pathology exists.(C) Biopsy of oral tissues(E) Excision of cysts and neoplasms(F) Treatment of palatal torus(G) Treatment of mandibular torus(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 (B) Pulpotomy and vital pulpotomy(C) Apexification filling with calcium hydroxide(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.(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.
(D) Osseous or muco-gingival surgery(6) Crowns 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 36 consecutive months, except when the crown is no longer functional as determined by the dental plan.2. Only acrylic crowns and stainless steel crowns are a benefit for children under 12 years of age. If other types of crowns are chosen as an optional benefit for children under 12 years of age, the covered dental benefit level will be that of an acrylic crown.3. 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.4. Veneers posterior to the second bicuspid 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 in a person 16 years of age or older and the patient's oral health and general dental condition permits. Under the age of 16, it is considered optional dental treatment. If performed on a subscriber under the age of 16, the applicant must pay the difference in cost between the fixed bridge and a space maintainer.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 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 36 consecutive months, unless: a. It is necessary due to natural tooth loss where the addition or replacement of teeth to the existing partial is not feasible, orb. The denture is unsatisfactory and cannot be made satisfactory2. 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 36 consecutive months unless the existing denture is unsatisfactory and cannot be made satisfactory by reline or repair.5. The covered dental benefit for complete dentures will be limited to the benefit level for a standard procedure. 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 as follows: One per arch in any 12 consecutive months.
(E) Tissue conditioning, limited to two per denture.(G) Implants are considered an optional benefit.(H) Stayplates, limited as follows: Stayplates are a benefit only when used as anterior space maintainers for children.
(8) Orthodontic Treatment, limited as follows: If the subscriber child meets the eligibility requirements for medically necessary orthodontia coverage under the California Children's Services program, benefits shall be provided and determined by the California Children's Services program.
(9) Other Dental Benefits (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 out-patient surgery setting is medically appropriate for dental services.(10) 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.(11)(A) Participating dental plans shall be responsible for identifying subscribers 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.(B) The plan is excused from responsibility from providing a covered service to treat the subscriber's CCS condition only to the extent that the treatment is authorized by the CCS program and provided by a CCS provider as described in the California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, Section 41412.(C) 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 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.Cal. Code Regs. Tit. 10, § 2699.6709
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. 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.
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) and (a)(3)(B), repealer of subsection (a)(3)(B)1., amendment of subsections (a)(4)(E), (a)(11) and (b)(2), new subsections (c) and (d) and amendment of NOTE filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).
6. Redesignation and amendment of former subsection (a)(11) as subsection (a)(11)(A), new subsections (a)(11)(B)-(C) and amendment of NOTE filed 6-30-2011, deemed an emergency pursuant to Insurance Code section 12693.22; operative 6-30-2011 (Register 2011, No. 26). A Certificate of Compliance must be transmitted to OAL by 12-27-2011 or the emergency action will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 6-30-2011 order transmitted to OAL 12-20-2011 and filed 2-3-2012 (Register 2012, No. 5). Note: Authority cited: Sections 12693.21, 12693.22, 12693.62 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.62, 12693.63 and 12693.64, Insurance Code.
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. 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.
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) and (a)(3)(B), repealer of subsection (a)(3)(B)1., amendment of subsections (a)(4)(E), (a)(11) and (b)(2), new subsections (c) and (d) and amendment of Note filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).
6. Redesignation and amendment of former subsection (a)(11) as subsection (a)(11)(A), new subsections (a)(11)(B)-(C) and amendment of Note filed 6-30-2011, deemed an emergency pursuant to Insurance Code section 12693.22; operative 6-30-2011 (Register 2011, No. 26). A Certificate of Compliance must be transmitted to OAL by 12-27-2011 or the emergency action will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 6-30-2011 order transmitted to OAL 12-20-2011 and filed 2-3-2012 (Register 2012, No. 5).