Colorado Essential Health Benefit for Children

Transcription

1 Smile fr Kids LOW EHB This summary f benefits, alng with the exclusins and limitatins describe the benefits f the Essential Health Benefit (EHB) fr Children. Please review clsely t understand all benefits, exclusins and limitatins. Child-ONLY* Essential Health Benefit Class I/Preventive Radigraphs (Periapical x-rays, bitewings), Exams, Cleanings, Fluride, Sealants, Space Maintainers, Emergency Pain Class II/Basic Radigraphs (Full Muth X-ray, Panramic Film), Restratins (Amalgams, Anterir Resins, and Pre- Fabricated Crwns), Simple Extractins, Cnsultatins and Anesthesia (General Anesthesia and Intravenus Sedatin) Class III/Majr Enddntics and Surgical Extractins Class IV/Orthdntia Only fr pre-authrized Medically Necessary Orthdntia Deductible (waived fr Class I) (per persn) Out f Pcket Maximum (OOP) (per persn) Out f Pcket Maximum*** (OOP) (per family - 2+ children) Annual Maximum Orth Lifetime Maximum Waiting Perid In-Netwrk Out-f- Netwrk** 100% 100% 80% 80% 50% 50% 50% fr medically necessary rthdntia $200 $350 $700 * This plan is available fr individuals up t age 19. **Benefits are based n the Usual and Custmary charges f the majrity f dentists in the same gegraphic area. ***2 family members must each meet the ut f pcket maximum in a plan year. Once fulfilled the family maximum has been met and will nt be applied t additinal family members. 1 P age

2 CLASSES OF COVERED SERVICES AND SUPPLIES (Individuals up t Age 19) Cverage is prvided fr the dental services and supplies described in this sectin. Please nte the age and frequency limitatins that apply fr certain prcedures. All frequency limits specified are applied t the day. Fr Yur Plicy, specific Cvered Services and Supplies may fall under a Class categry ther than what is stated belw. If Yur Plicy has Class categrizatins different frm belw, it is specified n the Schedule f Benefits. Class I: Preventive Dental Services Oral Exams Limited t twice in a 12 mnth perid fr any cmbinatin f ral exams X-Rays Bitewings limited nce every 12 mnths (nt a benefit in additin t a cmplete muth series) Prphylaxis (Cleaning) Limited t nce in a 12 mnth perid Tpical Fluride Treatment Limited t twice in a 12 mnth perid Sealants Sealant applicatins are limited t 1 per 36 mnth perid, n un-restred pit and fissures f a 1 st and 2 nd permanent mlar. Space Maintainer Only fr premature lss f deciduus (baby) psterir (back) teeth. Palliative Treatment Treatment f Emergency Pain Class II: Basic Dental Services X-Rays Full x-rays cmplete series (includes bitewings) limited t nce in 60 mnths. Panramic films limited t twice in a 12 mnth perid Amalgam (silver) Restratins Multiple restratins n 1 surface will be cnsiderd a single filling. Multiple restratins n different surfaces f the same tth will be cnsidered cnnected. Limited t nce in 24 mnths Resin (tth clred) Restratins Anterir (frnt) teeth ONLY Limited t nce in 24 mnths fr the same cvered amalgam (resin) restratin Resin (tth clred) Restratins Psterir (back) teeth ONLY Limited t the benefit f the crrespnding amalgam restratin Prir t placement member must be infrmed and agree t pay the cst difference Crnal remnants deciduus tth Peridntics (surgical peridntal services) Gingivectmy requires at least 6 mm pckets, and early bne lss. 5 mm pckets may be cnsidered in cnjunctin with 6 mm r mre pckets in the same quadrants. Osseus r muc-gingival surgery requires cmplete peridntal charting which indicate pckets in the range f 6 mm and abve, and mderate t severe bne lss Extractin f erupted teeth r expsed rt Cnsultatin, including specialist cnsultatins, limited as fllws: Cnsidered fr payment as a separate benefit nly if n ther treatment (except x-rays) is rendered n the same date. Benefits will nt be cnsidered fr payment if the purpse f the cnsultatin is t describe the Dental Treatment Plan General anesthesia and intravenus sedatin, limited as fllws: Cnsidered fr payment as a separate benefit nly when medically necessary (as determined by the Plan) and when 2 P age

3 administered in the Dentist s ffice r utpatient surgical center in cnjunctin with cmplex ral surgical services which are cvered under the Plicy. Nt a benefit fr the management f fear and anxiety Oral sedatin and nitrus xide are cvered fr children thrugh the age f 13 Class III: Majr Dental Services Therapeutic pulptmy (primary tth) excluding final restratin Benefit nly fr primary (baby) teeth Rt canal therapy (anterir/bicuspid/mlar) excluding final restratin Benefit fr permanent teeth nly. Recement crwn Prefabricated stainless steel crwn (primary and permanent teeth);prefabricated resin crwn (anterir teeth nly); Prefabricated stainless steel crwn with resin windw (anterir teeth nly) If mre than ne restratin is used t restre a tth, benefit allwance will be paid fr the mst inclusive service; Prefabricated crwns per tth are benefits nce in 24 mnth perid Surgical remval f erupted teeth Remval f impacted teeth Pathlgy remval f 3 rd mlar is nt a cvered benefit. Class IV: Orthdntia Orthdntia is cvered when medically necessary and pre apprved by the plan. General Exclusins Cvered Services and Supplies d nt include: 1) Treatment which: a) is nt included in the list f Cvered Services and Supplies; b) is nt Dentally Necessary; r c) is Experimental in nature. 2) Any Charges which are: a) Payable r reimbursable by r thrugh a plan r prgram f any gvernmental agency, except if the charge is related t a nnmilitary service disability and treatment is prvided by a gvernmental agency f the United States. Hwever, We will always reimburse any state r lcal medical assistance (Medicaid) agency fr Cvered Services and Supplies. b) Nt impsed against the persn r fr which the persn is nt liable. c) Reimbursable by Medicare Part A and Part B. If a persn at any time was entitled t enrll in the Medicare prgram (including Part B) but did nt d s, his r her benefits under this Plicy will be reduced by an amunt that wuld have been reimbursed by Medicare, where permitted by law. Hwever, fr persns insured under Emplyers wh ntify Us that they emply 20 r mre Emplyees during the previus business year, this exclusin will nt apply t an Actively at Wrk Emplyee and/r his r her spuse wh is age 65 r lder if the Emplyee elects 3 P age

4 cverage under this Plicy instead f cverage under Medicare. 3) Services r supplies resulting frm r in the curse f Yur r Yur Dependent s regular ccupatin fr pay r prfit fr which Yu r Yur Dependent are entitled t benefits under any Wrkers Cmpensatin Law, Emplyer s Liability Law r similar law. Yu must prmptly claim and ntify the Plan f all such benefits. 4) Services r supplies prvided by a Dentist, Dental Hygienist, denturist r dctr wh is: a) a Clse Relative r a persn wh rdinarily resides with Yu r a Dependent; b) an Emplyee f the Emplyer; c) the Emplyer. 5) Services and supplies which may nt reasnably be expected t successfully crrect the Cvered Persn s dental cnditin fr a perid f at least three years, as determined by the Plan. 6) All services fr which a claim is submitted mre than 6 mnths after the date f service. 7) Services and supplies prvided as ne dental prcedure, and cnsidered ne prcedure based n standard dental prcedure cdes, but separated int multiple prcedure cdes fr billing purpses. The Cvered Charge fr the Services is based n the single dental prcedure cde that accurately represents the treatment perfrmed. 8) Services and supplies prvided primarily fr csmetic purpses. 9) Cvered services and supplies btained while utside f the United States, except fr Emergency Dental Care. 10) Crrectin f cngenital cnditins r replacement f cngenitally missing permanent teeth nt cvered, regardless f the length f time the deciduus tth is retained. 11) Diagnstic casts, unless fr medically necessary rthdntia. 12) Educatinal prcedures, including but nt limited t ral hygiene, plaque cntrl r dietary instructins. 13) Persnal supplies r equipment, including but nt limited t water piks, tthbrushes, r flss hlders. 14) Restrative prcedures, rt canals and appliances which are prvided because f attritin, abrasin, ersin, wear, r fr csmetic purpses. 15) Appliances, inlays, cast restratins, crwns, r ther labratry prepared restratins used primarily fr the purpse f splinting. 16) Replacement f a lst r stlen Appliance r Prsthesis. 17) Replacement f stayplates. 18) Hspital r facility charges fr rm, supplies r emergency rm expenses, r rutine chest x-rays and medical exams prir t ral surgery. 19) Treatment fr a jaw fracture. 20) Services, supplies and appliances related t the change f vertical dimensin, restratin r maintenance f cclusin, splinting and stabilizing teeth fr peridntic reasns, bite registratin, bite analysis, attritin, ersin r abrasin, and treatment fr temprmandibular jint dysfunctin (TMJ), unless a TMJ benefit rider was included in the Plicy. 21) Therapeutic drug injectin. 22) Cmpletin f claim frms. 23) Missed dental appintments. 24) Prcelain and cast crwns 25) Crwns, inlays, cast restratins, r ther labratry prepared restratins n teeth which may be restred with an amalgam resin filling. 26) Pathlgy free third mlar extractin r remval. 27) Crwn build-up is nt cvered as a separate service. 28) Temprary tth stabilizatin, ther than cvered space maintainers, is nt cvered. 29) Oral sedatin and nitrus xide analgesia are nt cvered, except fr Children thrugh age ) Implants, and prcedures and appliances assciated with them, are nt benefits f Premier prgrams. 31) Replacement f missing teeth prir t cverage effective date. 4 P age

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