| (a) Each single service HMO evidence of coverage that
uses any dental procedure codes must use the codes as specified in
the current version of the CDT and certify that the codes referenced
in its evidence of coverage are as specified in the current version
of the CDT.
(b) Each single service HMO evidence of coverage providing
coverage for dental care services must provide benefits for covered
dental treatment in progress and may, if clearly disclosed, require
the enrollee to have the treatment completed by a participating provider
in the HMO delivery network, as defined in Insurance Code §843.002
(concerning Definitions), or as otherwise arranged by the single service
HMO.
(c) Each single service HMO evidence of coverage providing
coverage for dental care services and benefits must provide services
for the purposes of preventing, alleviating, curing, or healing dental
disease, including dental caries and periodontal disease. The services
may include an infection control (sterilization) fee. Single service
HMOs providing coverage for dental care services must provide coverage
for the following primary and preventive services provided by a general
dentist or hygienist, as applicable:
(1) office visit during and after regularly scheduled
hours;
(2) oral evaluations;
(3) X-rays;
(4) bitewings;
(5) panoramic film;
(6) dental prophylaxis (adult and child);
(7) topical fluoride treatment for children;
(8) dental sealants for children;
(9) amalgam fillings (one, two, three, and four or
more surfaces, primary and permanent, including polishing);
(10) anterior resin fillings (one, two, three, and
four or more surfaces, or involving incisal angle, primary and permanent,
including polishing);
(11) simple oral extractions;
(12) surgical incision and drainage of abscess, intraoral
soft tissue; and
(13) palliative (emergency) treatment of dental pain,
provided that the enrollee may obtain emergency treatment of dental
pain in a comparable facility.
(d) Each single service HMO evidence of coverage providing
coverage for dental care services and benefits may provide secondary
dental care services and benefits. Each single service HMO evidence
of coverage providing coverage for dental care services and benefits
may include an infection control (sterilization) fee, and may provide
secondary dental care services and benefits, including:
(1) posterior resin restorations, one, two, three,
and four or more surfaces (to include polishing);
(2) crowns and crown recementation;
(3) composite resin crowns, anterior-primary;
(4) sedative fillings;
(5) core buildup, including any pins, and pin retention;
(6) pulp cap (direct and indirect);
(7) therapeutic pulpotomy;
(8) root canal therapy, anterior, bicuspid, and molar;
(9) gingival curettage;
(10) osseous surgery;
(11) periodontal scaling and root planing;
(12) periodontal maintenance procedures;
(13) complete denture (maxillary and mandibular);
(14) partial denture (maxillary and mandibular);
(15) root removal-exposed roots;
(16) surgical removal of erupted tooth requiring elevation
of mucoperiosteal flap and removal of bone or section of tooth;
(17) removal of impacted tooth (soft tissue and completely
bony);
(18) tooth reimplantation or stabilization, or both,
of accidentally evulsed or displaced tooth or alveolus, or both;
(19) alveoplasty;
(20) occlusal guard (bruxism appliance); or
(21) orthodontia.
(e) Each single service HMO providing coverage for
dental care services and benefits may also offer a preventive services
plan as a supplement to a basic health care service plan offered by
an affiliate or another carrier, as long as a plan described in subsection
(c) of this section has first been offered to and rejected in writing
by the group contract holder. The preventive plan must include:
(1) oral evaluations;
(2) X-rays;
(3) bitewings;
(4) panoramic film; and
(5) prophylaxis.
|
