§ 2699.6709. Scope of Dental Benefits for Subscriber Children.
10 CA ADC § 2699.6709Barclays Official California Code of Regulations
10 CCR § 2699.6709
§ 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:
(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.
Five quadrant treatments in any 12 consecutive months.
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.
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.
One per arch in any 12 consecutive months.
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.
(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.
Credits
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.
History
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).
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 10, § 2699.6709, 10 CA ADC § 2699.6709
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