1. (a) Each single service HMO evidence of coverage which uses any dental procedure codes must use such codes as specified in the current version of CDT, as defined in §11.2200 of this title (relating to Definitions).
2. (b) Each single service HMO evidence of coverage providing coverage for dental care services shall provide benefits for covered dental treatment in progress and may, if clearly disclosed, require the enrollee to have such treatment completed by a participating provider in the Health Maintenance Organization Delivery Network, as defined under Insurance Code §843.002(15), or as otherwise arranged by the single service HMO.
3. (c) Each single service HMO evidence of coverage providing coverage for dental care services and benefits shall offer services for the purposes of preventing, alleviating, curing, or healing dental disease, including dental caries and periodontal disease. Such services may include an infection control (sterilization) fee. Single service HMOs providing coverage for dental care services shall offer coverage for the following primary and preventive services provided by a general dentist or hygienist, as applicable: office visit-during and after regularly scheduled hours; oral evaluations; x-rays; bitewings; panoramic film; dental prophylaxis (adult and child); topical fluoride treatment for children; dental sealants for children; amalgam fillings (one, two, three and four or more surface, primary and permanent-including polishing); anterior resin fillings (one, two, three and four or more surface or involving incisal angle, primary and permanent-including polishing); simple oral extractions; surgical incision and drainage of abscess-intraoral soft tissue; and palliative (emergency) treatment of dental pain.
4. (d) 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 posterior resin restorations, one, two, three and four or more surface (to include polishing); crowns and crown recementation; composite resin crowns, anterior-primary; sedative fillings; core buildup, including any pins, and pin retention; pulp cap (direct and indirect); therapeutic pulpotomy; root canal therapy, anterior, bicuspid and molar; gingival curettage; osseous surgery; periodontal scaling and root planing; periodontal maintenance procedures; complete denture (maxillary and mandibular); partial denture (maxillary and mandibular); root removal-exposed roots; surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth; removal of impacted tooth (soft tissue and completely bony); tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus; alveoplasty; occlusal guard (bruxism appliance); or orthodontia.
5. (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 section (c) of this section has first been offered to and rejected in writing by the group contract holder. Such a preventive plan shall include oral evaluations, X-rays, bitewings, panoramic film, and prophylaxis.

Source Note:The provisions of this §11.2203 adopted to be effective November 2, 1998, 23 TexReg 11347; amended to be effective February 24, 2005, 30 TexReg 854.