Dental Plan Available Services
Your dental plan has three categories of coverage. An annual individual deductible of $50 must be met before your dental plan reimburses you for services under Coverage B or Coverage C services. The deductible can be met with Coverage B and C services combined. Coverage is limited to $1,000 per person per calendar year. (2009 Plan Year: Dental exams, x-rays, cleanings and fluoride treatment do not apply to the $1,000 individual plan maximum.) Orthodontic services are not covered under this plan.
Coverage A: Diagnostic & Preventive - paid at 100% with no deductible
- Oral examinations (includes all types) - twice per calendar year.
- Bitewing radiographs (x-rays) - one set per calendar year.
- Dental prophylaxis (cleaning, scaling and polishing including periodontal maintenance visits) - twice per calendar year.
- Two additional cleanings allowed per calendar year for patients that are pregnant, diabetic, have a suppressed immune system or have a history of periodontal therapy. To be eligible for the additional cleaning benefits, you must submit a completed Self-Report form. If periodontal therapy has already been reported on your claims, the Self-Report form is not necessary.
- Topical fluoride application for patients up to age 14 - once per calendar year.
- Sealants for all eligible participants, limited to caries-free occlusal surfaces of the first and second permanent molars - once in 5 years.
- Brush biopsy to detect oral cancer.
Coverage B: Basic & Restorative - paid at 80% after $50 annual individual deductible is met
- Emergency palliative treatment (minor procedures to temporarily reduce or eliminate pain) - as needed.
- Space maintainers that replace prematurely lost teeth of eligible dependent children up to age 14 - once in five years.
- Restorative services using amalgam, synthetic porcelain and plastic filling material. See Also: Alternative Treatment Plans.
- Periapical radiographs (x-rays) - as required.
- Full-mouth radiographs (x-rays) - once in 5 years.
- Simple extractions.
Coverage C: Major Services - paid at 50% after $50 annual individual deductible
is met
There is a 12-month waiting period to qualify for these services.*
- Denture repairs and relines.
- Oral surgery, including surgical extractions, other than simple extractions in Coverage B.
- Periodontics: Treatment for diseases of the gums and bone supporting the teeth.
- Endodontics: Root canal filling and pulpal therapy.
- Prosthodontics (bridges, dentures, and partials).
- Dental benefits for an initial or replacement crown, jacket, labial veneer, inlay or onlay on or for a particular tooth will only be provided once in seven years, unless the damage to that tooth was caused by an accidental injury not related to the normal function of a tooth or teeth.
- General anesthesia: when administered by a dentist properly licensed to administer general anesthesia for a covered surgical procedure.
- Implants are not a covered benefit, however, an alternate benefit allowance will be provided based on the cost of a removable partial denture or fixed bridge - once in 7 years per tooth.
*The waiting period is waived with proof of 12-month continuous dental coverage for major services immediately prior to effective date of coverage in MCHCP’s dental plan.