1. (a) Every participating dental plan shall require copayments for the dental benefits provided to subscriber parents subject to the following:

   1. (1) No copayments shall be charged for benefits listed under Subsection 2699.6711(a)(1), “Diagnostic and Preventive.”

   2. (2) No copayments shall be charged for benefits listed under Subsection 2699.6711(a)(2), “Restorative Dentistry”, with the following exceptions:

      1. (A) Micro filled resin restorations (non-cosmetic, acid etched, bonded, light cured):

         1. 1. $40 per surface
         2. 2. $65 for two or more surfaces

   3. (3) No copayments shall be charged for benefits listed under subsection 2699.6711(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. Partially bony impaction -- $15 copayment.
         2. 2. Complete bony impaction -- $15 copayment.
      2. (B) Root recovery as a separate procedure -- $5 per root.

   4. (4) No copayments shall be charged for benefits listed under Subsection 2699.6711(a)(4), “Endodontics” with the following exceptions:

      1. (A) Root canal therapy or retreatment of previous root canal therapy (excluding restoration) is subject to copayments as follows:

         1. 1. 1 canal -- $20
         2. 2. 2 canals -- $40
         3. 3. 3 canals -- $60
         4. 4. 4 canals -- $80
      2. (B) An apicoectomy performed in conjunction with filling or root canal therapy at the same time is subject to a copayment of $60 per canal. When performed as a separate procedure, an apicoectomy is subject to a copayment of $50 per canal.

   5. (5) No copayments shall be charged for benefits listed under subsection 2699.6711(a)(5), “Periodontics”, with the following exceptions:

      1. (A) Osseous or muco-gingival surgery is subject to a copayment of $150 per quadrant (includes post surgical visits).
      2. (B) Gingivectomy is subject to a $5 copayment per tooth (fewer than six teeth).

   6. (6) No copayments shall be charged for benefits listed under subsection 2699.6711(a)(6), “Crowns and Bridges” (per unit), with the following exceptions:

      1. (A) Porcelain crowns; porcelain fused to metal crowns (excluding molars) full crowns, or ¾ crowns; are each subject to a copayment of $50. Cast post and core are subject to $40 per unit copayment, and bonded Maryland Bridge is subject to $50 copayment per unit.
      2. (B) Pontics are each subject to a copayment of $50.

   7. (7) “Removable Prosthetics” as listed under Subsection 2699.6711(a)(7) are subject to the following copayments:

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

         1. 1. Complete upper denture (3 adjustments within 60 days) -- $65.
         2. 2. Complete lower denture (3 adjustments within 60 days) -- $65.
         3. 3. Partial acrylic upper or lower denture with clasps -- $5.
         4. 4. Partial acrylic upper or lower denture with 2 chrome cobalt allow clasps is subject to a base fee of $65.
         5. 5. Partial lower or upper denture with chrome cobalt allow, lingual or palatal bar, clasps and acrylic saddles -- $65 base fee (included two clasps).
         6. 6. Removable unilateral partial denture -- $50.
         7. 7. Stayplate (maximum two teeth included) -- $60.

      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 -- $15 copayment.
      3. (C) Denture duplication -- $20 copayment.

      4. (D) Denture Repairs

         1. 1. Adding teeth to partial denture to replace natural tooth:

            First tooth -- $10 copayment.

            Each additional tooth -- $5 copayment.

         2. 2. Broken partial denture (no teeth involved) Replacement broken clasp -- $5 copayment.
         3. 3. Add clasp with rest -- $5 copayment.

   8. (8) Other Services After hour visit -- $35 copayment.

      Broken appointment -- $5 copayment.

   9. (9) Implants -- If implants are utilized, the plan will apply the cost of a standard full or partial denture towards the cost of implants and appliances constructed thereon, and if performed, subscriber parent must pay the difference plus any applicable copayment. Surgical removal of implants is not covered.
2. (b) No deductibles shall be charged to subscriber parents for dental benefits.
3. (c) 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 subscriber is American Indian or Alaska Native.
4. (d) Note: Any procedure not listed in the EOC is available on a fee-for-service basis.

Note: Authority cited: Sections 12693.21 and 12693.755, Insurance Code. Reference: Sections 12693.21, 12693.63 and 12693.755, 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 2699.6717 to section 2699.6721 and new section 2699.6717 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 (c) 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 (c) filed 7-1-2004 as an emergency; operative 7-1-2004 (Register 2004, No. 27). Pursuant to Section 80, A.B. 1762 (Chapter 230, Stats. 2003) a Certificate of Compliance must be transmitted to OAL by 12-28-2004 or emergency language will be repealed by operation of law on the following day.

8. Certificate of Compliance as to 7-1-2004 order transmitted to OAL 11-24-2004 and filed 1-7-2005 (Register 2005, No. 1).

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