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 2699.6717 - Share of Cost for Dental Benefits for Subscriber Parents

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every
				participating dental plan shall require copayments for the dental benefits
				provided to subscriber parents subject to the following:
(1) No copayments shall be charged for
				benefits listed under Subsection
				2699.6711(a)(1),
				"Diagnostic and Preventive."
(2) No
				copayments shall be charged for benefits listed under Subsection
				2699.6711(a)(2),
				"Restorative Dentistry", with the following exceptions:
(A) Micro filled resin restorations
				(non-cosmetic, acid etched, bonded, light cured):
1. $40 per surface
2. $65 for two or more
				surfaces
(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 3/4 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:
1. Complete upper denture (3 adjustments
				within 60 days) -- $65.
2. Complete
				lower denture (3 adjustments within 60 days) -- $65.
3. Partial acrylic upper or lower denture
				with clasps -- $5.
4. Partial
				acrylic upper or lower denture with 2 chrome cobalt allow clasps is subject to
				a base fee of $65.
5. Partial lower
				or upper denture with chrome cobalt allow, lingual or palatal bar, clasps and
				acrylic saddles -- $65 base fee (included two clasps).
6. Removable unilateral partial denture --
				$50.
7. Stayplate (maximum two
				teeth included) -- $60.
(B) Reline for an upper, lower or partial
				denture is subject to a copayment per unit as follows:
1. Office reline -- No copayment.
2. Laboratory reline -- $15
				copayment.
(C) Denture
				duplication -- $20 copayment.
(D)
				Denture Repairs
1. Adding teeth to partial
				denture to replace natural tooth:
First tooth -- $10 copayment.
Each additional tooth -- $5 copayment.
2. Broken partial denture (no teeth involved)
				Replacement broken clasp -- $5 copayment.
3. Add clasp with rest -- $5
				copayment.
(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.