California Benefits Description

Under the Medicaid State Plan dental benefits are provided to eligible individuals under the age of 21 in compliance with the requirements of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services.
State Program Name: not provided

Description of Dental Benefits Provided Under Children’s Health Insurance Program (CHIP)
CHIP Stand-Alone/Separate Program ONLY
State Program Name: Healthy Families Program (HFP)
Benchmark Equivalent Program
Program Name: California State Employees Benefits Program

Schedule of Services

• Recommended Age for First Oral Health Examination: 6 months of age

Preventive Services:

• Cleanings (Prophylaxis Services)
  Recommended frequency: Two in a 12 month period
  
• Fluoride treatments
  
• Sealants
  Exceptions: Limited as follows: Permanent first and second molars ONLY
  
• Space Maintainers
  Prior approval required: – Determined by the dental plan.

Diagnostic Services:

• Dental Examinations by Dentists
  Recommended age of first visit: 6 months of age
  
• Dental Screens and Other Services by Hygienists
  
• X-Rays
  Limits:
  
  1. Bitewing x-rays in conjunction with periodic examinations are limited to one series of four films in any 6 consecutive month period. Isolated bitewing or periapical films are allowed on an emergency or episodic basis.
  2. Full mouth x-rays in conjunction with periodic examinations are limited to once every 24 consecutive months.
  3. Panoramic film x-rays are limited to once every 24 consecutive months.

Treatment Services:

• Fillings
  1. Silver amalgam
  
  2. Tooth colored composite:
  Limits: (optional in posterior teeth)
  
• Crowns/Tooth Caps
  1. Stainless steel crowns:  Includes acrylic crowns for children under 12 years old.
  Limits: Replacement is once every 36 consecutive months or if medically necessary as determined by the plan.
  Prior approval required:
  
  2. Metal (only) crowns
  Limits: Replacement is once every 36 consecutive months or if medically necessary as determined by the plan.
  Prior approval required: Yes
  3. Metal/Porcelain crowns:
  Limits: Replacement is once every 36 consecutive months or if medically necessary as determined by the plan.
  Prior approval required:
  
  4. Porcelain (only):
  Limits: Replacement is once every 36 consecutive months or if medically necessary as determined by the plan.
  Prior approval required:
  
• Root Canals (endodontics)
  1. Root canals on baby teeth (Pulpotomies):
  Limits: Retreatment of root canals is a covered benefit only if clinical or radiographic signs of abscess formation are present, and/or the patient is experiencing symptoms. Removal or retreatment of silver points, overfills, underfills, incomplete fills, or broken instruments lodged in a canal, in the absence of pathology is not a covered benefit.
  Prior approval required: n/a
  
  2. Root canals on permanent teeth:
  Limits: Retreatment of root canals is a covered benefit only if clinical or radiographic signs of abscess formation are present, and/or the patient is experiencing symptoms. Removal or retreatment of silver points, overfills, underfills, incomplete fills, or broken instruments lodged in a canal, in the absence of pathology is not a covered benefit
  Prior approval required: n/a
  
• Gum (periodontal) Therapy
  Limits: 5 quadrant treatment in any 12 consecutive months
  Prior approval required: n/a
  
• Dentures
  1. Partial dentures
  Replacement is once every 36 consecutive months, unless due to natural tooth loss or denture is unsatisfactory or if medically necessary as determined by the plan.
  Prior approval required: n/a
• 2. Complete dentures
  The covered dental benefit for complete dentures will  be limited to the benefit level for a standard procedure. If a more personalized or specialized treatment is chosen by the patient and the dentist, the applicant will be responsible for all additional charges.
• Prior approval required: n/a
  
• Retainers (orthodontic)
  Limits: Available only if the subscriber child meets the eligibility requirements for medically necessary orthodontia coverage under the California Children’s Services Program (CCS). Benefits are be provided and determined by CCS.
  
• Bridges
  Limits
  1. Fixed bridges will be used only when a partial cannot satisfactorily restore the case. If fixed bridges are used when a partial could satisfactorily restore the case, it is considered optional treatment.
  
  2. A fixed bridge is covered when it is necessary to replace a missing permanent anterior tooth in a person 16 years of age or older and the patient’s oral health and general dental condition permits. Under the age of 16, it is considered optional dental treatment. If performed on a subscriber under the age of 16, the applicant must pay the difference in cost between the fixed bridge and a space maintainer.
  
  3. Fixed bridges used to replace missing posterior teeth are considered optional when the abutment teeth are dentally sound and would be crowned only for the purpose of supporting a pontic.
  
  4. Fixed bridges are optional when provided in connection with a partial denture on the same arch.
  
  5. Replacement of an existing fixed bridge is covered only when it cannot be made satisfactory by repair.
  Prior approval required: n/a
  
• Implants:
  Criteria: Implants are considered an optional benefit.
  
• Oral Surgery
  1. Simple extractions:
  Limits: Removal of impacted teeth, limited as follows: Surgical removal of impacted teeth is a covered benefit only when evidence of pathology exists.
  
  2. Surgical extractions:
  Limits: Removal of impacted teeth, limited as follows: Surgical removal of impacted teeth is a covered benefit only when evidence of pathology exists.
  
  3. Care of abscesses:
  
  4. Cleft palate treatment:
  Limits: EXCLUDED
  
  5. Cancer treatment:
  Limits: Biopsy oral tissues, excision of neoplasms.
  
  6. Treatment of Fractures:
  Limits: Major surgery for fractures.
  
  7. Biopsies:
  Limits: oral tissues
  
• Treatment of Jaw Joint (TMJ)
  Criteria: Varies by plan.
  Prior approval required: Yes
  
• Braces (Orthodontia)
  Criteria: Limited. Available only if the subscriber child meets the eligibility requirements for medically necessary orthodontia coverage under the California Children’s Services program (CCS). Benefits are be determined and provided by the CCS program.
  Prior approval required: CCS determines benefits.
  
• Emergency Room Services
  Identify services: Emergency Treatment
  
• Special Anesthesia
  Criteria: Oral sedatives when dispensed in a dental office by a practitioner acting within the scope of their licensure. General anesthesia and associated facility charges and outpatient services in connection with dental procedures when the use of a hospital or surgery center is necessary because of the subscriber’s medical condition or clinical status or because of the severity of the dental procedure.  This benefit is only available to subscribers under seven years of age; the developmentally disabled, regardless of age; and subscribers whose health is compromised and for whom general anesthesia is medically necessary, regardless of age.
  Prior approval required: Yes
  

Excluded Services

1. Identify services:
   
   Any benefits in excess of limits.
   
   Services, supplies, items, procedures or equipment, which are not medically necessary as determined by the plan.
   
   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.
   
   Any benefits that are received subsequent to the time the subscriber’s coverage ends.
   
   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.
   
   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.
   
   Procedures, appliances, or restorations to correct congenital or developmental malformations are not covered benefits unless specifically listed in program regulations.
   
   Cosmetic dental care.
   
   General anesthesia or intravenous/conscious sedation unless specifically listed as a benefit or is given by a dentist for covered oral surgery.
   
   Hospital charges of any kind.
   
   Major surgery for fractures and dislocations.
   
   Loss or theft of dentures or bridgework.
   
   Malignancies.
   
   Dispensing of drugs not normally supplied in a dental office.
   
   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.
   
   The cost of precious metals used in any form of dental benefits.
   
   The surgical removal of implants.
   
   Services of a pedodontist/pediatric dentist for subscriber children except when a subscriber child is unable to be treated by his or her provider, or treatment by a pedodontist/pediatric dentist is medically necessary, or his or her provider is a pedodontist/pediatric dentist.

State CHIP Contact
Lilia Coleman - lcoleman@mrmib.ca.gov