California Code of Regulations › Title 10 - Investment › Chapter 5.8 - Managed Risk Medical Insurance Board Healthy Families Program › Article 3 - Health, Dental and Vision Benefits › Section 2699.6713 - Excluded Dental Benefits for All Subscribers

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A dental benefits plan offered under this
				program shall exclude:
(1) Any benefits
				specified as excluded within Section
				2699.6709 or Section
				2699.6711.
(2) Any benefits in excess of limits
				specified in Section
				2699.6709 or Section
				2699.6711.
(3) Services, supplies, items, procedures or
				equipment, which are not medically necessary as determined by the plan, unless
				otherwise specified in Section
				2699.6709 or Section
				2699.6711.
(4) Any benefits received or costs that were
				incurred in connection with any dental procedures started prior to the
				subscriber's effective date of coverage. This exclusion does not apply to
				covered services to treat complications arising from services received prior to
				the subscriber's effective date of coverage.
(5) Any benefits that are received subsequent
				to the time the subscriber's coverage ends.
(6) Experimental or investigational services,
				including any treatment, therapy, procedure, drug or drug usage, facility or
				facility usage, equipment or equipment usage, device or device usage, or supply
				which is not recognized as being in accordance with generally accepted
				professional medical standards, or for which the safety and efficiency have not
				been determined for use in the treatment of a particular illness, injury or
				medical condition for which the item or service in question is recommended or
				prescribed.
(7) Dental services
				that are received in an emergency care setting for conditions that are not
				emergencies if the subscriber reasonably should have known that an emergency
				care situation did not exist.
(8)
				Procedures, appliances, or restorations to correct congenital or developmental
				malformations are not covered benefits unless specifically listed in Section
				2699.6709 or Section
				2699.6711.
(9) Cosmetic dental care.
(10) General anesthesia or
				intravenous/conscious sedation unless specifically listed as a benefit or is
				given by a dentist for covered oral surgery.
(11) Hospital charges of any kind.
(12) Major surgery for fractures and
				dislocations.
(13) Loss or theft of
				dentures or bridgework.
(14)
				Malignancies.
(15) Dispensing of
				drugs not normally supplied in a dental office.
(16) Additional treatment costs incurred
				because a dental procedure is unable to be performed in the dentist's office
				due to the general health and physical limitations of the subscriber.
(17) The cost of precious metals used in any
				form of dental benefits.
(18) The
				surgical removal of implants.
(19)
				Services of a pedodontist/pediatric dentist for subscriber children except when
				a subscriber child is unable to be treated by his or her panel provider, or
				treatment by a pedodontist/pediatric dentist is medically necessary, or his or
				her panel provider is a pedodontist/pediatric dentist.