Dental Services Rider Harbor Choice Plus, a product of Harbor Health Plan, Inc.

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1 Your Agreement gives You important information about Your health care benefits. This Dental Services Rider ( Rider ) is issued to You with Your Agreement because the plan you selected includes Other Dental Care Services for Children and Adults. It summarizes Your other dental care services benefits, including Covered Services, limitations and cost share obligations. Please keep Your Rider with Your Agreement. Harbor Health Plan, Inc. will notify You if any changes are needed. We are partnering with DENCAP Dental Plans, Inc. ( DENCAP ) to provide and administer the dental services that are Covered under this plan. If You have questions about the dental services Covered under this plan, please call Our Customer Service Department at (866) or TTY: (877) Access to Dental Care DENCAP contracts with dentists to provide dental services to Members. These contracted dentists are referred to as Participating Dentists. To find a Participating Dentist, visit: Please call Our Customer Service Department if You need help finding a Participating Dentist. Your primary care Participating Dentist is Your personal dentist. If You require specialty dental care, Your primary care Participating Dentist will arrange with DENCAP to refer You to a specialty dentist. It is important to keep Your scheduled appointments. If You need to cancel, please call the dental office within 24 hours before Your scheduled visit. You are responsible for any fees for missed appointments. You must use a Participating Dentist, except: If You need Emergency Treatment (see below); or You have Prior Approval. You can get a second opinion from a second dentist not treating You. Please contact Our Customer Service Department for more information. Prior Approval and Referrals Prior Approval and referrals may be required for certain services. Please call Our Customer Service Department for more information. Utilization Review All dental services claims are analyzed for utilization compliance and Adverse Determination per the frequencies and policies outlined in Limitations and Exclusions as well as any listed benefits and cost shares in this Rider. An Adverse Determination is a determination that the, availability of care or other health care service has been reviewed and denied, reduced or terminated because it is not medically necessary. Additionally, failure to respond in a timely manner to a request for determination constitutes an Adverse Determination. HHP_SilverHCPlusDentalRider_v3 Page 1 of 10

2 To obtain the clinical review criteria used to determine dental necessity in particular situations, please contact Our Customer Service Department. Appointment for Service Services are provided by appointment only. All reasonable efforts will be made to give appointments within 30 days of request. Emergencies and Out-of-Town Coverage Should an emergency arise after regular office hours, contact Your primary care Participating Dentist. If for any reason You are unable to contact Your primary care Participating Dentist, call the DENCAP Emergency Hotline at When You are at least 50 miles away from Your primary care Participating Dentist and an emergency arises, You should seek treatment from a dentist in the area. Emergency Treatment is defined in this Rider as dental services required to alleviate pain which, if not treated immediately, would result in jeopardy to Your dental health. Reimbursement is 50% of the amount up to $100 of only those emergency services which relieve severe pain or discomfort that are Covered Services. You must get follow-up treatment from Your primary care Participating Dentist. Notify Your primary care Participating Dentist so that follow-up treatment can be arranged. Please contact Our Customer Service Department for information on how to receive reimbursement. Member Cost Sharing You are responsible for any required Copays. Copays are listed in the Dental Services CPT Codes and Copays table in this Rider. Copays are due at the time of Your visit unless prior arrangements are made with Your dental center. Annual Maximum The total annual maximum under this plan is $2000. This encompasses: $1500 for primary care dentistry; and $500 for specialty care dentistry Maximums are for each individual covered under this plan. The annual maximum applies to dental services that are not Essential Health Benefits. There is no annual maximum on pediatric dental services that are Essential Health Benefits. Covered Services This Rider lists all of the dental services, procedures, treatments and supplies that are covered under this plan, the cost for each covered procedure and any limitations/exclusions that apply. Covered services, procedures, treatments and supplies are identified by current dental terminology (CDT) code. HHP_SilverHCPlusDentalRider_v3 Page 2 of 10

3 Covered Services are available only while You are covered under this plan. You are responsible for payment for any services not covered under this plan. Please note that benefits and coverage may vary based on patient s age at date of service. Pediatric Dental Care Services Pediatric dental care benefits are available for Members through the month of their 19 th birthday. Essential Health Benefits This plan includes coverage of pediatric dental services as required under the Patient Protection and Affordable Care Act and Michigan law; these services are Essential Health Benefits. Pediatric Essential Health Benefits are identified by an * in the Dental Services CPT Codes and Copays table in this Rider. These pediatric Essential Health Benefit services count towards Your Annual Out-of-Pocket Maximum. NOTE: For Members enrolled in a zero cost share plan there is no cost sharing for Pediatric Essential Health Benefits received from an Indian health organization dental provider or Participating Dentist. For Members enrolled in a limited cost share plan there is no cost sharing for Pediatric Essential Health Benefits received from an Indian health organization dental provider; Members must get a referral from Purchased/Referred Care to avoid cost sharing with any other Participating Dentist. Not Essential Health Benefits This plan also includes coverage of additional pediatric dental services which are not Essential Health Benefits. These services do not count towards Your Annual Out-of-Pocket Maximum. Adult Dental Care Services This plan includes coverage of adult dental care services. The adult dental care services covered under this plan are not Essential Health Benefits. These services do not count towards Your Annual Out-of- Pocket Maximum. Limitations and Exclusions Limitations Benefits are subject to the following limitations: Preventative Initial exam limited to once per year with a particular provider Periodic and limited examinations, including those by a specialist, are limited to twice per year Routine check-ups are limited to twice per year Prophylaxis (teeth cleaning), including periodontal cleanings, are limited to three per year (pediatric) and two per year (adult) Two additional cleanings may be allowed per year for patients that are pregnant, diabetic, have a suppressed immune system or have extensive periodontal history as determined by a dental professional Problem focused x-rays are allowed on an as needed basis as determined by the Member s HHP_SilverHCPlusDentalRider_v3 Page 3 of 10

4 dentist. Problem focused x-rays include all listed covered x-rays, including bitewings Prosthodontics A prosthodontic appliance, crown, inlay or bridge, placed solely to replace an existing serviceable appliance will not be provided When a prosthodontic appliance, crown, inlay or bridge is less than three years old, no replacement for said items is provided unless placement is needed because of the extraction of natural teeth during the same period of continuous coverage Restorative If a tooth can be restored with amalgam, composite or plastic, these will be the materials used to restore the tooth. The dentist providing the service makes the decision. The judgment will be solely that of the dentist providing the service. Mouth Rehabilitation If a patient and the dentist select a course of mouth rehabilitation, We cover only those benefits appropriate to eliminate oral disease and replace missing teeth as needed This does not include implants You are responsible for the balance of the treatment, including costs to increase vertical dimension or restore the occlusion Medically Necessary Orthodontics Children s orthodontics that are medically necessary are covered under this plan through Harbor Health Plan, Inc. as a medical/surgical benefit. Prior Approval is required. The member is responsible for the medical/surgical cost share applicable for the plan the Member is enrolled in. Please contact Our Customer Service Department for more information. Cosmetic Orthodontics Orthodontic care is provided when in the opinion of a Participating orthodontic consultant a satisfactory result can be achieved Treatment is limited to Class I and Class II cases and to 24 months Class I (Orthodontics): Neutrocclusion The molar relationship of the occlusion is normal or as described for the maxillary first molar, but the other teeth have problems like spacing, crowding, over or under eruption, etc. Class II (Orthodontics): Distocclusion (retrognathism, overjet) The upper molars are placed not in the mesiobuccal groove but anteriorly to it. Usually the mesiobuccal cusp rests in between the first mandibular molars and second premolars. Orthodontic records and case studies are not Maximum Benefit Cross bite in permanent dentition (teeth) will only be treated when, in the opinion of the orthodontist, the other conditions are present which would indicate that orthodontic treatment is necessary Coverage is up to $1800 of the usual and customary fee for Members under age 19 Coverage is up to $1200 of the usual customary fee for Members age 19 and over HHP_SilverHCPlusDentalRider_v3 Page 4 of 10

5 Cosmetic Interceptive Orthodontics Discounts for cosmetic interceptive orthodontics may be available at specific Participating Dentist locations Periodontics Services or supplies related to periodontal splinting or crown lengthening are not covered Pedodontics Services are provided for Members under the age of six with an approved referral by a Participating Dentist Exceptions are made on a case-by-case basis for emergency dental treatment and/or treatment special needs or disability NOTE: Additional charges apply for lab work. Additional charges may apply for gold or precious metals for all procedures involving crowns, bridges, prosthodontics, space maintainers, appliances and any repairs to such items Exclusions The following treatments are not covered under this plan: Dental services not in this Rider Dental treatment for cosmetic purposes only. Cosmetic dentistry includes procedures that improve the appearance of the dental structures such as dental implants, transplants or graft Services needed solely in connection with non-covered treatment Retreatment of root canal therapy within five years of original root canal, if final restoration has not been completed Dental treatment performed by a non-participating dentist Dental treatment performed in a hospital and/or any related hospital fee, except as provided in the Agreement Dental treatment performed due to systemic etiology such as ongoing treatment of mal-formed jaw/bone structure and dental services as a result of continuous repairs to such treatment Treatment of cleft lip, cleft palate, anodontia, mandibular prognathism and/or other maxillofacial or orthognathic deformities, except as provided in the Agreement Replacement of lost, stolen or missing prosthetic appliance(s) Replacement of prosthetic appliance(s) due to abuse, misuse or neglect Space maintainers, except when needed to preserve space resulting from premature loss of deciduous teeth Tooth preparation, temporary crowns, bases, impressions and anesthesia or other services which are part of the complete dental procedure. These services are considered components of, and included in the fee for, the complete procedure. Separate fees may not be charged by Participating dentists Charges for duplication of x-rays Additional charges that apply for lab fees and/or gold/precious metals for all procedures involving crowns, bridges, prosthodontics, space maintainers, appliances and any repairs to such items. Cases which in the professional judgment of the attending Provider or the DENCAP Dental Director, HHP_SilverHCPlusDentalRider_v3 Page 5 of 10

6 a satisfactory result cannot be obtained Treatment for any condition for which benefits of any nature are recovered or found to be recoverable, whether by adjudication or settlement under any Workers Compensation or Occupational Disease Law, even though You fail to claim the right to such benefits, provided that the exclusion shall only apply to the extent that such benefits are payable through such other plans Care or treatment obtained from or for which payment is made by any federal, state, county, municipal or other government agency, including any foreign government The cost of treatment not completed in a reasonable time frame after diagnosis due to delays by You Any treatment for or in connection with services, procedures, drugs or other supplies that are determined by DENCAP or Us to be experimental or still under clinical investigation by health professionals HHP_SilverHCPlusDentalRider_v3 Page 6 of 10

7 Dental Services CPT Codes and Copays CODE Copay CODE Copay DIAGNOSTIC AND PREVENTIVE ENDODONTICS 9999/ Office Visit (regular hours)/ $ / Pulp Cap (direct/indirect) $ Office visit (observation only) *Periodic Oral Evaluation $ *Therapeutic Pulpotomy $ *Limited Oral Evaluation - Problem Focused $ *Anterior Root Canal Therapy $ *Comprehensive Oral Evaluation $ *Bicuspid Root Canal Therapy $ Prediagnostic Test $ *Molar Root Canal Therapy $ Prophylaxis/Routine Cleaning - Adult $ Retreat of Previous Root Canal Therapy, anterior $ *Prophylaxis/Routine Cleaning - Child $ Retreat of Previous Root Canal Therapy, bicuspid $ *Topical Application of Fluoride - Varnish $ Retreat of Previous Root Canal Therapy, molar $ *Topical Application of Fluoride $ Apicoectomy/Periradicular Surgery, anterior $ Oral Hygiene Instructions $ Apicoectomy/Periradicular Surgery, bicuspid (first root) $ Local Anesthesia $ Apicoectomy/Periradicular Surgery, molar (first root) $350 X-RAYS 3426 Apicoectomy/Periradicular Surgery (each additional root) $ *Intraoral - Complete Series $ Retrograde Filling (per root) $ *Periapical - First radiographic image $5 PROSTHODONTICS 0230 *Periapical - Each Additional radiographic image $5 5110/ *Complete Upper/Lower Denture $ *Intraoral - Occlusal radiographic image $ / *Immediate Upper/Lower Denture $ *Bitewing - Single radiographic image $6 5211/ Partial Upper/Lower Denture - resin base $ *Bitewings - Two radiographic images $ / Partial Upper/Lower Denture- cast metal framework with $ resin 0273 *Bitewings - Three radiographic images $ / Partial Denture (interim) $ *Bitewings - Four radiographic images $ / Tissue Conditioning (per arch) $ *Panoramic radiographic image $ / Endosteel implant in conjunction with denture $ Pontic - cast predominantly base metal $ Pontic - cast noble metal $ Pontic - porcelain fused to predominantly base metal $445 HHP_SilverHCPlusDentalRider_v3 Page 7 of 10

8 Dental Services CPT Codes and Copays CODE Copay CODE Copay RESTORATIVE 6242 Pontic porcelain fused to noble metal $ *Amalgam Filling - One Surface $25 REPAIRS AND RELINES 2150 *Amalgam Filling - Two Surfaces $ / Denture/Partial adjustment (existing) $30 11/21/ *Amalgam Filling - Three Surfaces $ / Repair denture/partial (resin base) $ *Amalgam Filling - Four or More Surfaces $ / Replace missing/broken tooth on denture/partial $ Composite Filling - One Surface (Anterior) $ / Partial cast framework/repair or replace broken clasp $ Composite Filling - Two Surfaces (Anterior) $ Add tooth to existing partial denture $ Composite Filling - Three Surfaces (Anterior) $ Add clasp to existing partial denture $ Composite Filling - Four Surfaces (Anterior)/IA $ / Reline complete or partial denture (office) $140 31/40/ Composite Filling - One Surface (Posterior) $ / Reline complete or partial denture (lab) $160 51/60/ Composite Filling - Two Surfaces (Posterior) $50 ORAL SURGERY 2393 Composite Filling Three Surfaces (Posterior) $ *Extraction - coronal remnants (deciduous tooth) $ Composite Filling Four Surfaces (Posterior) $ *Extraction - erupted tooth or exposed root $40 ADJUNCTIVE 7210 Surgical removal of an erupted tooth $ Diagnostic Casts (each) $ Removal impacted tooth - soft tissue $ *Sealant - per tooth $ Removal impacted tooth - partially bony $ *Sealant repair per tooth $ Removal impacted tooth - completely bony $ *Unilateral - fixed (space maintainers) $ Removal impacted tooth - completely bony (complicated) $ *Bilateral fixed (space maintainers) $ Surgical removal of residual tooth roots $ *Unilateral removable (space maintainers) $ Surgical access of an unerupted tooth $ *Bilateral removable (space maintainers) $ Alveoloplasty in conjunction with extractions (4+ teeth or $80 spaces) 1550 Re-cementation of space maintainer $ Alveoloplasty in conjunction with extractions (1-3 teeth or spaces) $60 HHP_SilverHCPlusDentalRider_v3 Page 8 of 10

9 Dental Services CPT Codes and Copays CODE Copay CODE Copay 2910 Recement Inlay, Onlay or Partial Coverage $ Alveoloplasty not in conjunction with extractions (4+ teeth $120 Restoration or spaces) 2915 Recement cast or prefabricated Post and Core $ Alveoloplasty not in conjunction with extractions (1-3 teeth $100 or spaces) 2920 Recement Crown $ / Removal of exostosis/torus (per site) $205 2/ Protective Restoration (sedative filling) $ Incision and drainage of abscess (intraoral soft tissue) $ Recement Bridge (fixed partial denture) $ Inhalation of nitrous oxide $ *Palliative (Emergency) Treatment, minor procedure $ IV anesthesia (first 30 mins) $ *Consultation (Second Opinion) $ IV anesthesia (each additional 15 mins) $ Application of Desensitizing Medicament $20 PERIODONTICS 9940 Occlusal Guard (night guard) $ Comprehensive Periodontal Evaluation $ Occlusal Adjustment (limited) $ *Gingivectomy/Gingivoplasty (4+ teeth or spaces) $260 CROWNS 4211 *Gingivectomy/Gingivoplasty (1-3 teeth or spaces) $ Crown - resin-based composite (anterior) $ Gingival Flap Procedure (4+ teeth or spaces) $ *Crown - porcelain fused to predominantly base $ Gingival Flap Procedure (1-3 teeth or spaces) $270 metal 2752 *Crown - porcelain fused to noble metal $ Osseous Surgery (4+ teeth or spaces) $ / Crown - 3/4 cast predominantly base metal $ Osseous Surgery (1-3 teeth or spaces) $ / Crown - 3/4 cast noble metal $ *Perio Scaling/Root Planing (4+ teeth) $ / *Crown - full cast predominantly base metal $ *Perio Scaling/Root Planing (1-3 teeth) $ / *Crown - full cast noble metal $ Full Mouth Debridement $ Crown - provisional $ Site Specific Therapy (per tooth) $ / 31/ *Crown - prefabricated stainless steel $ Site Specific Therapy (per tooth) - Arestin $ / *Crown prefabricated resin $ Periodontal Maintenance $ Core Buildup (including any pins) $ Gingival Irrigation per quad $ Post and Core in addition to Crown $ Prefabricated Post and Core in addition to Crown $120 HHP_SilverHCPlusDentalRider_v3 Page 9 of 10

10 Dental Services CPT Codes and Copays CODE Copay CODE Copay 6751 Crown - porcelain fused to predominantly base $400 metal 6752 Crown - porcelain fused to noble metal $ / *Onlay - metallic $425 43/ / *Onlay - porcelain/ceramic $425 43/ / Onlay - resin-based composite $425 63/ *Crown porcelain/ceramic substrate $400 HHP_SilverHCPlusDentalRider_v3 Page 10 of 10

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