1. (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. (1) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(1), “Diagnostic and Preventive Benefits.”
   2. (2) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(2), “Restorative Dentistry.”

   3. (3) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(3), “Oral Surgery”, with the following exceptions:

      1. (A) Removal of impacted teeth is subject to a copayment per tooth as follows:

         1. 1. Soft tissue impaction -- No copayment.
         2. 2. Bony impaction -- $10 copayment per tooth.
      2. (B) Root recovery -- $10 per root.

   4. (4) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(4), “Endodontics”, with the following exceptions:

      1. (A) Root canal therapy -- $10 per canal. $10 copayment per canal for retreatment of previous root canal.
      2. (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. (5) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(5), “Periodontics”, with the following exceptions:

      1. (A) Osseous or muco-gingival surgery -- $10 per quadrant.
      2. (B) Gingivectomy -- no copayment.

   6. (6) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(6), “Crowns and Fixed Bridges” with the following exceptions:

      1. (A) Porcelain crowns; porcelain fused to metal crowns; full metal crowns; and gold onlays or ¾ crowns; are each subject to a copayment of $10.
      2. (B) Pontics are each subject to a copayment of $10.

   7. (7) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(7), “Removable Prosthetics”, with the following exceptions:

      1. (A) Dentures are subject to copayments as follows:

         1. 1. Complete maxillary denture -- $10.
         2. 2. Complete mandibular denture -- $10.
         3. 3. Partial acrylic upper or lower denture with clasps -- $10.
         4. 4. Partial upper or lower denture with chrome cobalt alloy lingual or palatal bar, clasps and acrylic saddles -- $10.
         5. 5. Removable unilateral partial denture -- $10.

      2. (B) Reline for an upper, lower or partial denture is subject to a copayment per unit as follows:

         1. 1. Office reline -- No copayment.
         2. 2. Laboratory reline -- $10.
      3. (C) Denture duplication -- $10.
   8. (8) No copayments shall be charged for benefits listed under Subsection 2699.6709(c)(8), “Orthodontia.”
   9. (9) No copayments shall be charged for benefits listed under Subsection 2699.6709(a)(9), “Other”.
   10. (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. (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.
2. (b) A fee of $10 shall be charged for failure to cancel an appointment without 24 hours prior notification.
3. (c) No deductibles shall be charged to subscriber children for dental benefits.
4. (d) No copayments or fees shall apply if the applicant has submitted acceptable documentation as described in Subsection 2699.6600(c)(1)(GG) that the applicant or the subscriber is American Indian or Alaska Native.

Note: Authority cited: Sections 12693.21 and 12693.22, Insurance Code. Reference: Sections 12693.21, 12693.22 and 12693.63, Insurance Code.

History

1. New section filed 2-20-98 as an emergency; operative 2-20-98 (Register 98, No. 8). A Certificate of Compliance must be transmitted to OAL by 6-22-98 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 2-20-98 order transmitted to OAL 6-5-98 and filed 7-15-98 (Register 98, No. 29).

3. Renumbering of former section 2699.6715 to section 2699.6719 and renumbering of former section 2699.6713 to section 2699.6715, including amendment of section heading, section and Note, filed 4-29-2002 as an emergency; operative 4-29-2002 (Register 2002, No. 18). Pursuant to Chapter 946, Statutes of 2000, section 2, a Certificate of Compliance must be transmitted to OAL by 10-28-2002 or emergency language will be repealed by operation of law on the following day.

4. Certificate of Compliance as to 4-29-2002 order transmitted to OAL 10-28-2002 and filed 12-12-2002 (Register 2002, No. 50).

5. Amendment of subsection (d) filed 7-31-2003 as an emergency; operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation of law on the following day.

6. Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No. 1).

7. Amendment of subsection (d) filed 1-7-2005; operative 1-7-2005 (Register 2005, No. 1).

8. Amendment of subsection (a)(4)(A) filed 9-15-2008; operative 10-15-2008 (Register 2008, No. 38).

9. Amendment of section and Note filed 10-29-2009; operative 11-1-2009 pursuant to Government Code section 11346.1(d) (Register 2009, No. 44). A Certificate of Compliance must be transmitted to OAL by 4-30-2010 or emergency action will be repealed by operation of law on the following day. This regulatory action is deemed to meet the emergency standard and is exempt from OAL review pursuant to Insurance Code section 12693.22.

10. Certificate of Compliance as to 10-29-2009 order transmitted to OAL 4-27-2010 and filed 6-9-2010 (Register 2010, No. 24).