(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 ¾ 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:
(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.
Credits
Note: Authority cited: Sections 12693.21 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.63 and 12693.755, 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. 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).
