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 2699.6715 - Share of Cost for Dental Benefits for Subscriber Children

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Every
				participating dental plan shall require copayments for the dental benefits
				listed in Subsection
				2699.6709 (a) of
				these regulations provided to subscribers subject to the following except that
				subscribers with household income at or below 150% of the Federal Poverty Level
				shall pay a $5 copayment when a copayment is required:
(1) No copayments shall be charged for
				benefits listed under Subsection
				2699.6709(a)(1),
				"Diagnostic and Preventive Benefits."
(2) No copayments shall be charged for
				benefits listed under Subsection
				2699.6709(a)(2),
				"Restorative Dentistry."
(3) No
				copayments shall be charged for benefits listed under Subsection
				2699.6709(a)(3),
				"Oral Surgery", with the following exceptions:
(A) Removal of impacted teeth is subject to a
				copayment per tooth as follows:
1. Soft
				tissue impaction -- No copayment.
2. Bony impaction -- $10 copayment per
				tooth.
(B) Root recovery
				-- $10 per root.
(4) No
				copayments shall be charged for benefits listed under Subsection
				2699.6709(a)(4),
				"Endodontics", with the following exceptions:
(A) Root canal therapy -- $10 per canal. $10
				copayment per canal for retreatment of previous root canal.
(B) An apicoectomy performed in conjunction
				with root canal therapy is subject to a copayment of $10 per canal. When
				performed as a separate procedure, an apicoectomy is subject to a copayment of
				$10 per canal.
(5) No
				copayments shall be charged for benefits listed under Subsection
				2699.6709(a)(5),
				"Periodontics", with the following exceptions:
(A) Osseous or muco-gingival surgery -- $10
				per quadrant.
(B) Gingivectomy --
				no copayment.
(6) No
				copayments shall be charged for benefits listed under Subsection
				2699.6709(a)(6),
				"Crowns and Fixed Bridges" with the following exceptions:
(A) Porcelain crowns; porcelain fused to
				metal crowns; full metal crowns; and gold onlays or 3/4 crowns; are each
				subject to a copayment of $10.
(B)
				Pontics are each subject to a copayment of $10.
(7) No copayments shall be charged for
				benefits listed under Subsection
				2699.6709(a)(7),
				"Removable Prosthetics", with the following exceptions:
(A) Dentures are subject to copayments as
				follows:
1. Complete maxillary denture --
				$10.
2. Complete mandibular denture
				-- $10.
3. Partial acrylic upper or
				lower denture with clasps -- $10.
4. Partial upper or lower denture with chrome
				cobalt alloy lingual or palatal bar, clasps and acrylic saddles --
				$10.
5. Removable unilateral
				partial denture -- $10.
(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 --
				$10.
(C) Denture
				duplication -- $10.
(8)
				No copayments shall be charged for benefits listed under Subsection
				2699.6709(c)(8),
				"Orthodontia."
(9) No copayments
				shall be charged for benefits listed under Subsection
				2699.6709(a)(9),
				"Other".
(10) The copayment for any
				precious (noble) metals used in any crown or bridge will be the full cost of
				the actual precious metal used.
(11) Notwithstanding any other provision in
				this section, an alternative copayment shall apply under the following
				circumstances: For children under six years of age, who are unable to be
				treated by their panel provider, and who have been referred to a
				pedodontist/pediatric dentist, the copayment is $10.