PEDIATRIC DENTAL BENEFITS RIDER As described in this Rider, the Certificate of Coverage is modified as stated below. This Rider is applicable to Certificates of Coverage issued in the State of Ohio. Any provision of this Rider which is in conflict with the requirements of state or federal statutes or regulations (of the jurisdiction in which the Rider is delivered) is hereby amended to conform to the minimum requirements of such statutes and regulations. If this rider is attached, it supersedes the Pediatric dental benefits and exclusions shown in the Certificate of Coverage. All terms used herein have the same meaning given to them in the Certificate of Coverage, unless otherwise specifically defined herein. PHP-IND-OH-HMO-PDR-2015
Schedule of Benefits Covered expenses for pediatric dental care apply toward Your Deductible, Coinsurance, or Out-of-Pocket Limit. Covered Expense Class I services Plan Pays for Services From Network Providers 0% after Deductible Class II services 30% after Deductible Class III services 50% after Deductible Class IV services 50% after Deductible - 2 -
DEFINITIONS Dental Emergency A sudden, serious dental condition caused by an accident or dental disease that, if not treated immediately, would result in serious harm to the dental health of the Pediatric Member. Palliative Dental Care Treatment used in a Dental Emergency to relieve, ease, or alleviate the acute severity of dental pain, swelling, or bleeding. Palliative dental care treatment usually is performed for, but is not limited to, the following acute conditions: 1. Toothache; 2. Localized infection; 3. Muscular pain; or 4. Sensitivity and irritations of the soft tissue Services are not considered palliative dental care when used in associated with any other Pediatric Dental Services, except x-rays and/or exams Pediatric Clinical Review The review of required/submitted documentation by a Dentist for the determination of pediatric Dental Services. Pediatric Dental Services Includes the following services: 1. Ordered by a Dentist; 2. Described in the Pediatric Dental Care section of this rider; and 3. Incurred when the Pediatric Member is insured for that benefit under this policy/certificate on the expensive incurred date. Pediatric Member A member who is under the age of 19. THE FOLLOWING PEDIATRIC DENTAL BENEFIT IS ADDED TO THE BENEFITS SECTION: Pediatric Dental Benefits Covered Services include Pediatric Dental Services for Pediatric Member(s). Pediatric Dental Services include the following as categorized below. Coverage for a Dental Emergency is limited to Palliative Dental Care only. Class I services: Periodic evaluations. Limited to one every six months. This Benefit is not available when a comprehensive oral evaluation is performed. Comprehensive oral evaluation. Limited to one every six months. Benefit is not available when any other evaluation is performed. Limited, problem-focused oral evaluation, limited to a maximum of one evaluation every six months. Periodontal evaluations, limited to one every six months. This Benefit allowed only for a Pediatric Member showing signs or symptoms of periodontal disease, and for patients with risk factors such as smoking, diabetes or related health issues. This Benefit is not available when any other oral evaluation is performed. Cleaning, including all scaling and polishing procedures, limited to one every six months. Intraoral complete series x-rays (at least eight films, including bitewings) or panoramic x-ray, - 3 -
limited to one complete set of x-rays every 60 months, or one panoramic x-ray every 60 months. Bitewing x-rays for pediatric members, limited to one set every six months for members. Pediatric members are limited to one set per twelve months. Other x-rays, including intra-oral periapical, and occlusal x-rays, limited to medically necessary x-rays for the purpose of diagnosis or prescription of a specific treatment. Topical fluoride treatment, limited to two applications every 12 months. Application of sealants to the occlusal surface of permanent molars that are free of tooth decay and restorations, limited to one sealant per tooth every 36 months. Installation of initial space maintainers for retaining space when a primary tooth is prematurely lost. Recementation of space maintainers for pediatric members. Class II services: Restorative services as follows: Amalgam restorations (fillings), limited to five surfaces per tooth every 12 months. Multiple fillings on one surface are considered one filling. Composite restorations (fillings) on front teeth, limited to five surfaces per tooth every 12 months. Fillings on molar and bicuspid teeth are considered an alternate service and will be payable as an amalgam filling. The member will be responsible for the remaining expense incurred. Multiple fillings on one surface are considered one filling. Pin retention per tooth in addition to restoration, not payable with core buildup. Post and core build-up, limited to one every five calendar years. Pre-fabricated stainless steel, esthetic stainless steel, and resin crowns on primary or permanent teeth that cannot be properly restored with normal fillings. This benefit is limited to one tooth every 60 months. The following simple oral surgical services are limited to once per tooth of the pediatric member: Removal of coronal remnants of a deciduous tooth Removal of an erupted tooth or exposed root for permanent and primary teeth Other services as follows: Recementing of inlays, onlays, crowns, and bridges. Dental emergency care for the treatment of pain or an accidental dental injury to the teeth and supporting structures. We will consider the service a separate benefit only if no other service is provided during the same visit. X-rays and problem-focused oral evaluations are an exception. Diagnostic consultations provided by a dentist or other provider not providing the treatment, limited to one consultation per calendar year. Repairs of bridges, dentures, and crowns. Class III services: Restorative services as follows: Initial placement of synthetic restorations for a permanent restoration, when the tooth cannot be restored with a direct placement filling material due to extensive decay or a traumatic injury. Pediatric dental services include inlays, onlays, crowns, core build-ups and posts, and implant supported crowns and abutments. This benefit is limited to one per tooth every five calendar years. Initial placement of inlays, onlays, crowns, or other synthetic restorations for primary and permanent teeth. Benefits include the replacement of the existing major restoration if: - 4 -
It has been five calendar years since the prior insertion and the prior insertion is not, and cannot be, made serviceable The restoration is damaged beyond repair due to an accidental dental injury while in the oral cavity Extraction of functioning teeth, excluding third molars or teeth not fully blocked by an opposing tooth or prosthesis, requires the replacement of the prosthesis Periodontic services as follows: Periodontal scaling and root planning, limited to one per quadrant every 24 months, and limited to two quadrants per visit. Additional quadrants are considered pediatric dental services when the service is performed one day following the completion of the initial quadrants. Periodontal maintenance (at least 30 days following periodontal therapy), limited to four every 12 months. This benefit is not payable if a cleaning is done at the same visit. Periodontal and osseous surgical procedures, including bone replacement, tissue regeneration, and/or grafting. This benefit is limited to one per quadrant every 36 months. If more than one surgical procedure is performed on the same day, only the most inclusive procedure will be considered a pediatric dental service. Separate fees for pre and post-operative care and re-evaluation within three months are not payable as separate pediatric dental services Endodontic procedures as follows: Root canal therapy for permanent teeth, limited to one per tooth of the pediatric member. Any test, intraoperative, x-ray, laboratory, or any other follow-up care considered integral to the therapy. Periradicular surgical procedures for permanent teeth, including apicoectomy, root amputation, tooth reimplantation, or surgical isolation are limited to one procedure per tooth. Partial pulpotomy for apexogenesis for permanent teeth, limited to one procedure per tooth. Vital pulpotomy for permanent and primary teeth, limited to one procedure per tooth. Pulpal therapy (resorbable) for primary teeth, limited to one service per tooth. Apexification/recalcification for permanent teeth, limited to one service per tooth. Prosthodontics services as follows: Denture adjustments when done by dentist other than the initial adjustment, or adjustments done more than six months after initial installation. This benefit is limited to one service every 12 months. Initial replacement of bridges and dentures, limited to one every 60 months. Pediatric dental services include pontics and crowns, limited to one every five calendar years. Replacement of bridges and dentures for permanent teeth include the replacement of the existing prosthesis if: It has been 60 months since the prior insertion and the insertion is not, and cannot be, made serviceable. The prosthesis is damaged beyond repair due to an accidental dental injury while in the oral cavity. Extraction of functioning teeth, excluding third molars or teeth not fully blocked by an opposing tooth or prostheses requires the replacement of the prosthesis. Tissue conditioning, limited to one every 12 months. Denture relines or rebases, limited to one every 36 months, after six months of installation. The following oral surgical services are limited to one tooth: - 5 -
Surgical extractions Bone smoothing Trimming or removal of overgrowth or non-vital tissue or bone Removal of tooth or root from sinus and closing opening between mouth and sinus Surgical access of an erupted tooth Mobilization of erupted or malpositioned tooth to aid eruption, or surgical reposition of teeth Excision of removal of benign oral cysts or tumors Note: If more than one surgical procedure is performed on the same day, only the most inclusive procedure will be considered a pediatric dental service. Implant services, subject to pediatric clinical review and performed only when medically necessary. This benefit includes implant-supported crowns, abutments, bridges, and dentures. Implant-supported complete or partial dentures are limited to one every five years. All other services limited to a maximum of one every 60 months. General anesthesia or conscience sedation, subject to pediatric clinical review and managed by dentist with covered oral, periodontal, bone, and periradicular surgical procedures or dental services. Class IV services Orthodontic treatment, subject to pediatric clinical review, and when necessary due to a congenital or developmental malformation related to or developed due to a cleft palate, with or without cleft lip. Pediatric dental services include the treatment of, and appliances for tooth guidance, harmful habits, and interception and correction. Pediatric dental services also include x-rays, exams, and follow-up care. This benefit is limited to a maximum of one course of treatment per member. Integral services Integral services are additional charges related to materials or equipment used in the delivery of dental care. The following services are considered integral to the dental service and will not be paid separately: Local anesthetics Bases Pulp testing Pulp caps Treatment plans Occlusal (biting or grinding surfaces of molar and bicuspid teeth) adjustments Nitrous oxide Irrigation Tissue preparation associated with impression or placement of a restoration] Pretreatment plan We suggest that if dental treatment is expected to exceed $300, the dentist should submit a treatment plan to us for review before treatment begins. The treatment plan should include: A list of services to be done using the American Dental Association terminology and codes - 6 -
The dentist s written description of the proposed treatment for the pediatric member Pretreatment x-rays supporting the services to be done Itemized cost of the proposed treatment Any other appropriate diagnostic materials that we may request We will provide you or the pediatric member and the dentist with an estimate for benefits payable based on the submitted treatment plan. The estimate is not a guarantee of what we will pay. It tells you or the pediatric member and the dentist in advance about the benefits payable for the pediatric dental services in the treatment plan. An estimate for services is not necessary for a dental emergency. An estimate for services is valid for 90 days after the date we notify you and/or the pediatric member and dentist of the benefits payable for the proposed treatment plan, and is subject to the pediatric member s eligibility of coverage. If treatment will not begin for more than 90 days after the date we notify you and/or the pediatric member and the dentist, we require a new treatment plan to be submitted. Alternative services If two or more services are acceptable to correct a dental condition, we will base the benefits payable on the least expensive pediatric dental service that produces a professionally satisfactory result, as determined by us. We will pay up to the plan allowance for the least costly pediatric dental service. The service is subject to any applicable medical deductible, pediatric dental deductible, and/or co-insurance. See the SOB for pediatric dental deductible and coinsurance amounts. The member will be responsible for any amount exceeding the plan allowance for the services performed. If you or the pediatric member and the dentist decide on a more costly service, payment will be limited to the plan allowance for the least costly service and will be subject to any medical deductible, pediatric dental deductible, and coinsurance. THE FOLLOWING PEDIATRIC DENTAL CARE EXCLUSION IS ADDED TO THE LIMITS AND EXCLUSIONS SECTION: What s Not Covered Unless specifically stated otherwise, no benefit will be provided for the following: Any expense arising from the completion of forms Any expense due to a member s failure to keep an appointment Any expense for a service we consider cosmetic, unless it is due to an accidental dental injury Expenses incurred for: o Precision or semi-precision attachments o Overdentures and any endodontic treatment associated with overdentures o Other customized attachments o Any services for 3D image (cone beam images) o Temporary and interim dental services o Additional charges related to materials or equipment used in the delivery of dental care - 7 -
Charges by a family member or person who resides with the pediatric member Any services related to: o Altering vertical dimension of teeth or changing the spacing and/or shape of the teeth o Restoration or maintenance of occlusion o Splinting teeth, including multiple abutments, or any service to stability of periodontally-weakened teeth o Replacing tooth structures lost due to abrasion, attrition, erosion, or abfraction o Bite registration or bite analysis Infection control Expenses incurred for services done by someone other than a dentist (exception for scaling and teeth cleaning and the topical application of fluoride, which may be done by a licensed dental hygienist) o Treatment must be performed under the supervision and guidance of a licensed dentist in accordance with generally accepted standards Any hospital, surgical, or treatment facility, or for services of an anesthesiologist or anesthetist Prescription drugs or pre-medications, whether dispensed or prescribed Any service that: o Is not eligible for benefits based on the Pediatric Clinical Review o Does not offer a favorable prognosis o Does not have uniform professional acceptance o Is deemed experimental or investigational in nature Repair and replacement of orthodontic appliances Preventive control programs such as oral hygiene instructions, plaque control, take-home items, prescriptions, and dietary planning Replacement of any lost, stolen, damaged, misplaced, or duplicate major restoration, prosthesis or appliance Any susceptibility testing, laboratory tests, saliva samples, anaerobic cultures, sensitivity testing, or charges for oral pathology procedures Services and treatment not prescribed by or under the direct supervision of a dentist, except in those states where dental hygienists are permitted to practice without supervision by a dentist. In these states, we will pay for eligible covered services provided by an authorized dental hygienist performing within the scope of his or her license and applicable state law; Services and treatment which are experimental or investigational; Services and treatment which are for any illness or bodily injury which occurs in the course of employment if a benefit or compensation is available, in whole or in part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not you claim the benefits or compensation; Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, VA hospital or similar person or group; Services and treatment performed prior to your effective date of coverage; - 8 -
Services and treatment incurred after the termination date of your coverage unless otherwise indicated; Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice. Services and treatment resulting from your failure to comply with professionally prescribed treatment; Telephone consultations; Any charges for failure to keep a scheduled appointment; Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances; Services related to the diagnosis and treatment of Temporomandibular Joint Dysfunction (TMD); Services or treatment provided as a result of intentionally self-inflicted injury or illness; Services or treatment provided as a result of injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation, or participating in a riot, rebellion or insurrection; Office infection control charges; Charges for copies of your records, charts or x-rays, or any costs associated with forwarding/mailing copies of your records, charts or x-rays; State or territorial taxes on dental services performed; Those submitted by a dentist, which is for the same services performed on the same date for the same member by another dentist; Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law; Those for which the member would have no obligation to pay in the absence of this or any similar coverage; Those which are for specialized procedures and techniques; Those performed by a dentist who is compensated by a facility for similar covered services performed for members; Duplicate, provisional and temporary devices, appliances, and services; Plaque control programs, oral hygiene instruction, and dietary instructions; Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth; Gold foil restorations; Treatment or services for injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan; Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization; Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient); Charges by the provider for completing dental forms; - 9 -
Adjustment of a denture or bridgework which is made within 6 months after installation by the same Dentist who installed it; Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners; Cone Beam Imaging and Cone Beam MRI procedures; Sealants for teeth other than permanent molars; Precision attachments, personalization, precious metal bases and other specialized techniques; Replacement of dentures that have been lost, stolen or misplaced; Orthodontic services provided to a dependent of an enrolled member who has not met the 24 month waiting period requirement. Orthodontic care for dependent children age 19 and over; Repair of damaged orthodontic appliances; Replacement of lost or missing appliances; Fabrication of athletic mouth guard; Internal and external bleaching; Nitrous oxide; Oral sedation; Topical medicament center Orthodontic care for a member or spouse Bone grafts when done in connection with extractions, apicoetomies or non-covered/non eligible implants. - 10 -